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in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/genitourinarysurOOwhit 


Spirocheta  pallida,  the  lightly  stained  organisms.  Those  stained  with  the  darker  stain  are  the 
Spirocheta  refnngens  which  are  found  in  conditions  other  than  syphilis.  Spirocheta  pallida  is  about 
7  microns  in  length  and  varies  from  an  immeasurable  thinness  to  .b  of  a  micron  in  width.  Its 
curves  vary  in  number  from  3  to  12,  and  it  is  extremely  motile.  The  ends  are  distinctly  pointed. 
This  is  demonstrable  in  enlarged  glands,  chancres,  mucous  patches,  and  flat  condylomata,  and  has 
apparently  been  successfully  inoculated  upon  the  chimpanzee,  though  not  in  pure  culture.  It  is 
extremely  difficult  to  see  in  the  fresh  state  and  is  refractory  to  staining  even  after  prolonged  con- 
tact with  the  dye.  The  best  results  have  been  obtained  with  Giemsa's  azure-eosin  mixture  applied 
from  one  to  twenty-four  hours.  The  material  to  be  examined  is  spread  upon  a  cover-glass  or  slide, 
fixed  in  absolute  alcohol  for  ten  to  twenty  minutes,  and  the  stain  is  then  applied.  It  does  not  stain 
by  Gram's  method.     (Dr.  Handle  C.  Rosenberger.) 


Genito-Urinary  Surgery 


AND 


Venereal  Diseases 


BY 

J.  WILLIAM  WHITE,  M.D. 

JOHN   RHEA   BARTON   PROFESSOR   OF  SURGERY,   UNIVERSITY   OF    PENNSYLVANIA 

AND 

EDWARD  MARTIN,  M.D. 

PROFESSOR   OF   CLINICAL  SURGERY.   UNIVERSITY   OF   PENNSYLVANIA 


Illustrated  with   Three  Hundred  Engravings  and  Fourteen 
Colored  Plates 


NINTH     EDITION 


PHILADELPHIA    AND    LONDON 

J.  B.  LIPPINCOTT   COMPANY 


'-'^UCMX, 


Copyright,    1897,   by  J.   B.  Lippincott  Company 


Copyright,   1900,  by  J.   B.  Lippincott  CkjMPANY 


Copyright,   1902,  by  J.  B.  Lippincott  Company 


Copyright,   1905,  by  J.  B.  Lippincott  Company 


Copyright,   1906,  by  J.  B.  Lippincott  Company 


Copyright,  1907,  by  J.  B.  Lippincott  Company 


Copyright,   1910,   by  J.   B.  Lippincott   Company 


E-EOmOTYPED  AND  PRINTED  BY  J.  B.  LIPPINCOTT  COMPANY,  PHILADELPHIA,  U.S.A. 


PREFACE  TO  THE  EIGHTH  EDITION. 


The  printing  of  eight  editions  of  this  work  in  ten  years  has  enabled 
the  authors  to  make  from  year  to  year  such  alterations  and  additions 
as  are  called  for  by  betterments  in  diagnosis,  treatment,  armamenta- 
rium, and  technique. 

Thus,  after  a  careful  study  of  the  newer  methods  of  diagnosing  renal 
permeability,  we  have  asserted  our  belief  that  none  compare  in  sim- 
plicity and  reliability  with  urea  estimates  of  the  urine  drawn  separately 
from  each  kidney.  We  have  been  convinced  that  renal  tuberculosis 
should  be  treated  by  nephrectomy  in  its  early  stage,  and  while  it  is 
still  unilateral.  We  have  found  in  Bierhoff's  Catheterizing  Cystoscope 
an  instrument  more  generally  satisfactory  than  any  we  have  heretofore 
used.  Moynihan's  ingenious  operation  for  the  cure  of  bladder  exstro- 
phy seems  better  to  fulfil  the  requirements  of  the  case  than  those 
recognized  as  classic. 

We  have  incorporated  in  the  text  only  such  changes  as  have  been 
generally  accepted  by  those  most  competent  to  judge  of  their  merits. 


PREFACE  TO  THE   SIXTH  EDITION. 


The  sixth  edition  of  Genito-Urinary  Surgery  and  Venereal  Diseases 
has  been  revised  in  accordance  with  the  latest  teaching  and  practice 
of  those  most  skilled  in  this  branch  of  surgery.  This  has  involved  a 
study  of  current  literature  and  a  selection  from  it  of  such  facts  and 
procedures  as  have  been  proven  worthy  of  general  acceptance. 
Though  the  technique  of  the  genito-urinary  specialist  has  not  been 
revolutionized  in  the  last  two  years,  it  has  in  many  respects  been 
greatly  improved.  It  has  been  our  purpose  to  embody  in  this  text- 
book all  these  improvements.  It  has  seemed  desirable  to  insert 
many  new  illustrations,  and  in  some  cases,  notably  in  discussing 
prostatic  hypertrophy,  to  rewrite  some  sections.  We  have  endeav- 
ored to  improve  the  book  without  enlarging  it,  and  to  make  the 
teaching  still  more  clear,  direct,  and  practical. 


PREFACE  TO  THE  FIFTH  EDITION. 


In  this  fifth  edition  of  Genito-Urinary  Surgery  we  have  carefully 
avoided  an  attempt  to  epitomize  current  literature,  and  have  thus 
omitted  methods  of  examination  and  treatment  which  have  been 
accepted  with  approval  by  some  practitioners  and  specialists.  We 
have  added  to  the  text  only  such  practical  modern  procedures  as 
our  own  experience  and  judgment  have  shown  to  be  of  distinct 
value. 


PREFACE  TO  THE  FIRST  EDITION. 


In  the  preparation  of  this  work  we  have  endeavored  to  present 
clearly  and  with  sufficient  detail  the  generally  accepted  teachings  of 
the  day  in  regard  to  the  pathology,  symptomatology,  diagnosis,  and 
treatment  of  syphilis  and  genito-urinary  diseases. 

We  have  exercised  the  author's  right  of  choice  in  estimating  the 
comparative  value  of  various  methods  of  treatment,  and  have  given 
chiefly  those  which  our  experience  has  led  us  to  prefer,  though  alter- 
native methods  are  usually  mentioned.  As  it  was  our  wish  to  make 
this  book  one  of  practical  use  to  the  physician,  much  space  has  been 
devoted  to  symptomatology,  diagnosis,  and  treatment.  The  patho- 
logical alterations  characteristic  of  the  diseases  and  injuries  described 
have  been  briefly  outlined,  avoiding  discussion  of  questions  still  un- 
settled. Historical  considerations  have  been  abbreviated  as  much  as 
possible,  and  references  have  been  omitted,  though  proper  credit  has 
been  given  for  special  methods  or  teachings. 

Emphasis  has  been  laid  upon  genito-urinary  antisepsis  and  the 
details  of  operative  and  manipulative  technique,  since  thorough  un- 
derstanding of  these  matters  must  form  the  foundation  for  all  good 
work  in  genito-urinary  surgery. 

The  modern  methods  of  examination  of  the  various  portions  of  the 
urinary  and  genital  systems  have  been  described  with  fulness,  since 
only  upon  familiarity  with  them  can  exact  diagnosis  and  scientific 
therapeutics  be  based. 

We  have  included  an  exceptionally  comprehensive  study  of  the 
changes  in  the  urine  and  its  constituents  produced  by  disease,  a  sub- 
ject so  intimately  connected  with  the  specialty  to  which  this  work  is 
devoted  as  to  deserve  much  more  attention  than  it  usually  receives 
in  surgical  text-books. 


vm  PKEPACE. 

While  we  have  freely,  discussed  established  facts  relating  to  the 
recognition  or  treatment  of  disease  or  injury,  and  important  theories 
bearing  on  questions  of  surgical  therapeutics,  we  have  tried  to  avoid 
the  confusion  which  is  apt  to  result  from  the  effort  to  be  encyclo- 
paedic. Our  views  have  been  put  in  such  form  as  to  be  of  practical 
use  to  the  general  practitioner  and  the  medical  student,  since  we  feel 
that  our  experience  as  hospital  surgeons  and  as  teachers  during  a 
number  of  years  has  familiarized  us  with  their  needs. 

In  the  sections  on  Stricture  of  the  Urethra  and  Treatment  of 
Syphilis  we  have  used  portions  of  the  articles  on  those  subjects  con- 
tributed by  Dr.  White  to  the  volumes  on  Genito-Urinary  Diseases 
and  Syphilology  of  Morrow's  System  of  Genito-Urinary  Diseases, 
Syphilology,  and  Dermatology. 

We  must  also  express  our  thanks  to  Dr.  G.  H.  Fox  for  placing  at 
our  disposal  his  admirable  collection  of  photographs,  to  Messrs. 
Charles  Lentz  &  Sons,  of  Philadelphia,  for  the  illustrations  of  sur- 
gical instruments  contained  in  the  volume,  to  Mr.  Joseph  McCreery 
for  his  aid  in  the  correction  of  the  proofs,  to  Mr.  Samuel  Macmeney 
for  much  kindness  in  seeing  the  book  through  the  press,  and  to  Mr. 
G.  E.  H.  Weaver  for  preparation  of  the  index. 

J.  William  White. 
Edward  Martin. 

Philadelphia,  January,  1897. 


CONTENTS. 


CHAPTER     I 

DISEASES    AND    INJURIES    OF   THE    PENIS 

PAGE 

Anatomy  of  the  Penis — ^Anomalies  of  the  Penis — Anomalies  of  the  Prepuce 
— Narrowing  of  the  Preputial  Orifice — Phimosis — Circumcision — Para- 
phimosis— Shortness  of  the  Frsenum. — Injuries  of  the  Penis — Contu- 
sion— Wounds  of  the  Penis — Fracture  of  the  Penis — Dislocation  of  the 
Penis.— Inflammatory  Affections  of  the  Penis — Acute  Inflammation 
of  the  Penis — Chronic  Inflammation  of  the  Erectile  Tissue — Inflamma- 
tory Lymphangitis  —  Phlebitis  —  Balanitis  and  Balanoposthitis  — 
Herpes  Progenitalis. — Chancroid — ^The  Clinical  Aspects  of  Chancroid 
— Coiriplications  of  Chancroid — Treatment  of  Chancroid — Treatment 
of  the  Complications  of  Chancroid. — Tumors  of  the  Penis — Cyst, 
Fibroma,  Angioma,  etc. — Lymphangioma  or  Elephantiasis — Verrucse, 
or  Papillomata — Horny  Growths  of  the  Penis — Malignant  Disease — 
Partial  Amputation  of  the  Penis — Amputation  of  the  Entire  Penis . .     1-67 


CHAPTER     II 

INJTJRIES    AND   DISEASES    OF   THE   URETHRA 

Anatomy  of  the  Urethra — ^Malformations  of  the  Urethra — Hypospadia — 
Epispadia. — Injuries  of  the  ITrethra — Lacerated  and  Contused  Wounds 
— Rupture  of  the  Urethra. — Foreign  Bodies  in  the  Urethra. — "Urethral 
Calculi      68-101 


CHAPTER     III 

AFFECTIONS    CHARACTERIZED    BY   URETHRAL   DISCHARGE 

Urethrorrhcea — Urethritis. — Traumatic  Urethritis — Irritative  Urethritis — 
Eruptive  Urethritis — Mechanical  Urethritis — Cancer  of  the  Urethra — 
Concomitant  Urethritis — Specific  Urethritis — Syphilitic  Urethritis — 
Chancroidal  Urethritis — Tubercular  Urethritis — Typhoidal  Urethritis 
— Influenzal  Urethritis — Pneumococcic  Urethritis — Diphtheritic  Ure- 
thritis.— Gonorrhoea — Typical  Acute  Gonorrhoea  of  the  Male  Urethra 
— Treatment  of  Acute  Gonorrhoea  in  the  Male — Systematic  Treatment 
of  Acute  Gonorrhoea — Subacute  or  Catarrhal  Gonorrhoea. — Chronic 
Gonorrhoea — Chronic  Anterior  Urethritis — Chronic  Posterior  Ure- 
thritis  , 102-167 


X  CONTENTS. 

CHAPTER     IV 

GONOEBHCEA   IN    WOMEN 

PAGE 

Frequency  of  the  Disease — Seat  of  Infection — Contagion — Symptoms — 
Diagnosis. — Urethritis — Acute  Urethritis — Chronic  Urethritis — Fol- 
liculitis.— Vulvitis. — Bartholinitis — Acute  Bartholinitis — Chronic  Bar- 
tholinitis.— Metritis — Acute  IMetritis — Chronic  ]\Ietritis — Gonorrhoeal 
Salpingitis  and  Oophoritis — Perimetritis. — Vaginitis. — Gonorrhoea  in 
Children — Male  Children — Female  Children — Catarrhal  Vulvo-Vagi- 
nitis — Gonorrhoeal  Vulvo- Vaginitis    168-183 

CHAPTER     V 

COMPLICATIONS    OF   GONORRHCEA 

Balanitis  and  Balanoposthitis — Phimosis — Paraphimosis — Lymphangitis — 
Lymphadenitis,  or  Bubo — Follicular  and  Periurethral  Abscess — Pros- 
tatitis— Vesiculitis — Epididymitis. — Extragenital  and  Systemic  Gon- 
orrhoea—Cystitis— Ureteritis,  Pyelitis,  and  Xephritis — Gonorrhoea  of 
the  Rectum. — Gonorrhoea  of  the  Eye — Gonorrhoeal  Conjunctivitis — 
Rhevimatic  Gonorrhoeal  Ophthalmia.  —  Gonorrhoeal  Rheumatism  — 
Arthritis— Tenosynovitis— Phlebitis     184-202 

$ 

CHAPTER     VI 

STRICTURE    OF   THE   URETHRA 

Inflammatory  Stricture — Spasmodic  Stricture — Organic  Stricture — Clinical 
Forms  of  Stricture — Location  of  Stricture — Changes  in  the  Urethra. — 
Symptoms  of  Stricture — Subjective  Symptoms — Objective  Symptoms — 
Diagnosis. — Results  of  Stricture — Extravasation  of  Urine — Effect  on 
Bladder — Ureters — Kidneys — Prognosis  of  Stricture. — Treatment  of 
Organic  Stricture  —  Gradual  Dilatation  —  Cleansing  the  Urethra  — 
Passing  the  Sound — Strictures  of  Small  Calibre — Strictures  of  Small 
Calibre  permeable  only  to  Filiform  Bougies. — Urethrotomy — Internal 
Urethrotomy — Indications  for  Performance  of  Internal  Urethrotomy — 
Internal  Urethrotomy  from  before  Backward — Internal  L'rethrotomy 
from  behind  Forward — External  Perineal  Urethrotomy — External 
Perineal  Urethrotomy  with  a  Guide,  or  Syme's  Operation — General 
Indication  for  External  Urethrotomy — Combined  Internal  and  External 
Urethrotomy — Perineal  Section — Drainage  after  External  Urethrot- 
omy and  Perineal  Section  —  Miscellaneoiis  Methods  —  Summary  of 
Treatment. — Stricture  of  the  Female  Urethra 203-257 

CHAPTER     VII 

URETHRAL   FEVER,   ETC. 

Urethral  Fever — Acute  Urinary  Fever — Chronic  Urinary  Fever. — Fistula 
of  the  Urethra  —  Urethro-Rectal  Fistulse  —  Urethro-Perineo-Scrotal 
Fistula — Urethro-Penile  Fistula. — Urethral  Pouches. — Urethral  Neo- 
plasms— Diseases  of  Cowper's  Glands — Cowperitis — Cysts  of  Cowper's 
Glands — Cancer  of  Cowper's  Glands. — Urethroscopy — Examination — 
Appearance  of  the  Urethra. — The  Care  of  Urethral  Instruments.  . .   258-284 


CONTENTS.  Xi 

CHAPTER     VIII 

THE  GENERAL  SYMPTOMATOLOGY  OF  DISEASES  OF  THE  URINARY  TRACT — EXAMINATION 

OF    THE    URINE 

Pain — The  Character  and  Intensity  of  the  Pain — The  Region  of  the  Pain — 
The  Relation  of  the  Pain  to  the  Act  of  Micturition — Frequency  of 
Urination — Alterations  in  the  Stream — Suppression  of  Urine — Reten- 
tion of  Urine — The  Effects  of  Retention — Retention  due  to  Paresis  or 
Incoordination  of  the  Bladder  Muscles — Retention  from  Congestion 
or  Acute  Inflammation — Retention  from  Blocking  of  the  Urethra  or 
Vesical  Neck. — Retention  from  Prostatic  Enlargement — Symptoms — 
Diagnosis— Treatment — Incomplete  Retention. — Retention  from  Stric- 
ture— Treatment — Retention  from  Traumatism. — Incontinence  of  TJrine 
— Incontinence  without  Lesions  of  the  Urinary  Tract — Incontinence  in 
Children — Diagnosis — Treatment — Incontinence  with  Lesions  of  the  Uri- 
nary Tract — Hsematuria — Treatment  of  Hismaturia- — Examination  of  the 
Urine — Alterations  in  the  Quantity  of  Urine — Alterations  in  the  Spe- 
cific Gravity — Alterations  in  Color — Alterations  in  Reaction — Quan- 
titative Alterations  of  Normal  Constituents. — Abnormal  Substances 
in  the  TTrine — Serum-Albumin,  etc. — Hsematuria — Haemoglobinuria — 
Carbohydrates,  etc. — Bacteriuria — Pneumaturia. — The  Sediments  in 
the  TJrine — Blood,  Pus,  Casts,  etc. — Technique  of  Examination  of  the 
Urine  for  the  Usual  Pathological  Constituents 285-366 

CHAPTER     IX 

CYSTOSCOPY EXAMINATION    OF    URINE    FROM    EACH    KIDNEY    SEPARATELY  —  EENAI, 

CAPABILITY — SURGICAL   TREATMENT    OF    NEPHRITIS 

Cystoscopes — Method  of  Using  the  Cystoscope — Cystoscopic  Diagnosis — Cys- 
toscopic  Appearances — Errors  to  be  avoided  in  Cystoscopy — Cystoscopic 
Diagnosis  of  Vesical  Tumors — Examination  of  the  Urine  from  each 
Kidney  separately — Massage  of  the  Kidneys — Ureteral  Catheteriza- 
tion— Segregation  of  the  Urine — Determination  of  Renal  Capability — 
Surgical  Treatment  in  the  Presence  of  Renal  Insufficiency — Surgical 
Treatment  of  Nephritis 307-3S6 

CHAPTER    X 

INJURIES   AND   DISEASES   OP   THE   BLADDER 

Anatomy.— Malformations  and  Malposition  of  the  Bladder— Multiple  Bladder 
— Complete  Absence  of  the  Bladder — Exstrophy — Treatment— Patent 
Urachus— Congenital  Diverticulum — Hypertrophy  of  the  Bladder — Atro- 
phy of  the  Bladder — Atony  of  the  Bladder — "Wounds,  Contusion,  and 
Rupture  of  the  Bladder — Wounds  of  the  Bladder — Complications  of 
Wounds  of  the  Bladder — Contusion  of  the  Bladder — Rupture  of  the 
Bladder 387-411 

CHAPTER    XI 

CYSTITIS — VESICAL   TUBERCULOSIS VESICAL   SYPHILIS— VESICAL   FISTULA 

Cystitis — Classification — Etiology — Superficial  or  Catarrhal  Cystitis— In- 
terstitial Cystitis — Membranous  Cystitis — Gangrenous  Cystitis— Peri- 
Cystitis  —  Symptoms  of  Cystitis  —  Diagnosis  —  Prognosis  —  Treatment. 


Xii  CONTENTS. 

PAGE 

— Perivesical  Inflammation — Perivesical  Abscess. — Tuberculosis  of  the 
Bladder — Etiology — Pathological  Anatomy — Symptoms — Diagnosis — 
Prognosis — Treatment. — Syphilis  of  the  Bladder — Fistula  of  the  Blad- 
der— Symptoms — Diagnosis — Treatment 412-439 


CHAPTER     XII 

CALCULUS   OF   THE   BLADDER — TUMORS   OF   THE   BLADDER 

Vesical  Calculus — ^Uric  Acid  Calculi — ^Urate  Calculi — Phosphatic  Calculi — 
Calcium  Oxalate  Calculi — Calcium  Carbonate  Calculi — Cystin  Calculi 
— Etiology  of  Calculi  —  Symptoms  —  Diagnosis — Prognosis  —  Prophy- 
laxis —  Treatment. — Litholapaxy — Perineal  Litholapaxy — Litholapaxy 
in  Children  —  Contra-Indications  to  Litholapaxy  —  Complications  of 
Litholapaxy. — Lithotomy — Perineal  Lithotomy — Lateral  Lithotomy — 
After-Treatment  of  Perineal  Lithotomy  Cases — ^Median  Lithotomy — 
Bilateral  Lithotomy — ^Medio-Bilateral  Lithotomy — Suprapubic  Lithot- 
omy— ^After-Treatment  of  Suprapubic  Lithotomy  Cases — Complications 
and  Sequelae  of  Suprapubic  Cystotomy — Treatment  of  Vesical  Calculi 
in  Women. — Foreign  Bodies  in  the  Bladder. — Tumors  of  the  Blad- 
der.— Papilloma — ^IVIyxoma — Fibroma — Myoma —  Sarcoma —  Carcinoma 
— Diagnosis — Treatment — Operative  Treatment — Extirpation  of  the 
Bladder — Cystic  Tumors  of  the  Bladder — Varicose  Veins  of  the  Blad- 
der— Paravesical  Tumors 440-503 

CHAPTER     XIII 

DISEASES    AND   INJURIES    OF    THE   URETERS 

Anatomy — ^Anomalies — Wounds  and  Rupture  of  the  Ureters — Treatment — 
Ureteritis  —  Stricture  of  the  Ureter — Treatment — Calculus  of  the 
Ureter — Symptoms — Diagnosis — Prognosis — Treatment — Fistula  of  the 
Ureter — Tuberculosis  of  the  Ureter — Tumors  of  the  Ureter — Prolapse 
of  the  Ureter 504-523 

CHAPTER     XIV 

INJURIES    AND   DISEASES   OF   THE   KIDNEYS 

jjfurgical  Anatomy — Anomalies  of  the  Kidney — Floating  Kidney — ^Movable 
Kidney — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. — 
Injuries  to  the  Kidney — Contusion  of  the  Kidney — Symptoms — ^Diag- 
nosis— Prognosis  —  Treatment — Wounds  of  the  Kidney — Nephrec- 
tomy       524-549 

CHAPTER     XV 

KIDNEY   CALCULI 

eymptoms — ^Diagnosis — Prognosis — Treatment — Nephrolitotomy    550-564 

CHAPTER     XVI 

SUPPURATIVE  DISEASES   OF  THE  KIDNEY 
Pyelitis — Pyonephrosis  —  Pyelonephritis  —  Suppurative     Nephritis — Peri- 
nephritis— Pyelo-Paranephric  Cyst — Renal  Infarct   565-588 


CONTENTS.  Xiii 

CHAPTER     XVII 

HYDEONEPHROSIS RENAL  TUBERCULOSIS — RENAL  FISTULA — PARASITES  AND  TUMORS 

FAGB 

Hydronephrosis — Congenital  Hydronephrosis — Acquired  Hydronephrosis — 
Symptoms — Diagnosis — Prognosis — Treatment. — Tuberculosis  of  the 
Kidney — Acute  Kenal  Tuberculosis — Chronic  Renal  Tuberculosis — 
Symptoms  —  Diagnosis — Prognosis  —  Treatment.  —  Renal  Fistulae.  — 
Neoplasms  of  the  Kidney — Epithelial  Tumors — Tumors  of  Connective- 
Tissue  Origin — Tumors  of  Heterogeneous  Origin. — Cysts  of  the  Kid- 
ney.— Parasites  of  the  Kidneys. — The  Suprarenal  Capsules — Hyper- 
nephroma      589-614 

CHAPTER     XVIII 

INJURIES    AND    DISEASES    OF   THE    SCROTUM    AND   TESTICLES 

Anatomy  .-^Diseases  of  the  Scrotum — Deformities — Injuries  of  the  Scrotum 
— Wounds  of  the  Scrotum — CEdema  of  the  Scrotum — Emphysema — The 
Cutaneous  Affections  of  the  Scrotum — Gangrene  of  the  Scrotum — 
Elephantiasis — Tumors  of  the  Scrotum. — Anomalies  of  the  Testicles — 
Anomalies  in  Number — Anomalies  in  Size — Anomalies  in  Migration — 
Complications  of  Misplaced  Testicles — Treatment — Inversion  of  the 
Testicle — Luxation  of  the  Testicle — Torsion  of  the  Testicle. — Con- 
tusions and  Wounds  of  the  Testicle — Contusions — Symptoms — Diag- 
nosis — •  Prognosis  —  Treatment  —  Epididymo-Orchitis  from  Strain  — 
Wounds  of  the  Testicle.  —  Inflammation  of  the  Testicle  —  Urethral 
Epididymitis —  Symptoms —  Prognosis —  Treatment —  Epididymo-Orchi- 
tis complicating  Acute  Infectious  Diseases— Orchitis  complicating 
Mumps — Typhoid  Orchitis — Malarial  Orchitis — Orchitis  following 
Tonsillitis — Gouty  Orchitis — Orchitis  following  Smallpox,  Scarlatina, 
or  Influenza — Abscess  of  the  Testicle — Gangrene  or  Necrosis  of  the 
Testicle — Fungus  or  Hernia  of  the  Testicle. — Tubercular  Disease  of 
the  Testicle — Symptoms — Diagnosis — Prognosis — Treatment — Syphilis 
of  the  Testicle  and  Epididymis. — Tumors  of  the  Testicle — Carcinoma 
— Sarcoma — Encysted  Hydrocele  of  the  Epididymis  and  Testis — Cysts 
of  the  Testis — Enchondroma  —  Lymphadenoma  —  Fibroma  —  Dermoid 
Cysts — Myxoma,  Osteoma,  and  Myoma. — Castration. — Hydrocele. — 
Acute  Hydrocele. — Chronic  Hydrocele — Hydrocele  of  the  Tunica  Vagi- 
nalis Testis — Symptoms — Diagnosis — Prognosis — Treatment — Excision 
—  Congenital  Hydrocele  —  Infantile  Hydrocele  —  Inguinal  Hydrocele 
— Fatty  Hydrocele. — Hydrocele  of  the  Cord — Diffuse  Hydrocele  of  the 
Cord — Encysted  Hydrocele  of  the  Cord— Hydrocele  into  a  Hernial  Sac 
Haematocele — Hsematocele  of  the  Tunica  Vaginalis — Chronic  Hsema- 
tocele  of  the  Tunica  Vaginalis — Encysted  Haematocele  of  the  Testis — 
Intratesticular  Hsematocele — Haematocele  of  the  Cord — Loose  Bodies  in 
the  Tunica  Vaginalis.— Neuralgia  of  the  Testicles 615-70] 

C  LI  AFTER    XIX 

INJURIES   AND   DISEASES   OF   THE   SPERMATIC    CORD   AND   SEMINAL   VESICLES 

Contusions  and  Wounds  of  the  Cord — Inflammation  of  the  Cord — Tumors 
of  the  Cord — Tuberculosis — Varicocele. — The  Seminal  Vesicles — Anom- 
alies of  the   Seminal   Vesicles  —  Injuries  of  the  Seminal  Vesicles  — 


Xiv  CONTENTS. 

PAGE 

Vesiculitis  or  Spermatocystitis — Cystic  Swelling  of  the  Seminal  Vesi- 
cles— Spermatocystic  Concretions — Tuberculosis  of  the  Seminal  Vesi- 
cles— Malignant  Growth   702-718 

CHAPTER     XX 

INJUBIES    AND   DISEASES    OF   THE   PBOSTATE 

Anatomy  of  the  Prostate. — Contusions  and  Wounds  of  the  Prostate — 
Contusion  of  the  Prostate — Wounds  of  the  Prostate. — Prostatitis — 
Causes — Pathology — Symptoms — Diagnosis —  Prognosis  — Treatment — - 
Chronic  Prostatitis — Irritable  Prostate. — Tuberculosis  of  the  Pros- 
tate.—  Enlargement  of  the  Prostate — Pathology — Etiology — Symp- 
toms—  Diagnosis — Prognosis.  —  Treatment  of  Enlarged  Prostate  — 
Palliative  Treatment — Hygienic  Treatment — Medicinal  Treatment — 
Intermittent  Dilatation — Rectal  Injections — Catheterism — Stretching 
of  the  Internal  Vesical  Sphincter. — Prostatotomy — Perineal  Prosta- 
totomy  performed  with  the  Knife  —  Galvano-Cautery  Prostatotomy 
through  a  Perineal  Opening.— Prostatectomy — Suprapubic  Prostatectomy 
— Prostatectomy  by  JMedian  Perineal  Incision— Perineal  Prostatectomy 
by  Transverse  Incision— The  Results  of  Prostatectomy— Castration  and 
Vasectomy— Castration.-Atrophy  of  the  Prostate.— Prostatic  Calculi.— 
Malignant  Tumors  of  the  Prostate— Carcinoma — Cysts  of  the  Prostate. .  .719-776 

CHAPTER    XXI 

SEXUAL    WEAKNESS   AND   STERILITY 

TMechanism  of  Erection — Organic  Impotence — Psychical  Impotence — ^Atonic 
Impotence — Genito-Urinary  Neuroses — The  Diagnosis  of  Atonic  Impo- 
tence— Treatment —  Prostatorrhoea —  Treatment —  Involuntary  Seminal 
Emissions — Nocturnal  Pollutions  —  Diurnal  Pollutions  —  Spermator- 
rhoea— Treatment — Priapism — Impotence  in  the  Female. — Sterility — 
Aspermia  —  Oligospermia  —  Oligozoospermia  —  AzK)ospermia  —  Treat- 
ment       777-804 

CHAPTER     XXII 

PSYCHOPATHIA   SEXUALIS 

Sexual  Hypersesthesia — Onanism — Treatment  of  Onanism  in  Children — 
Treatment  of  Onanism  in  Adolescents  and  Adults — Satyriasis  and 
Nymphomania — Sexual  Anaesthesia — Sexual  Parsesthesia — Algolignia — 
Masochism — Homosexuality —  Psychical  Hermaphroditism —  Urnings — 
Elfemination  and  Viraginity — Androgyny  and  Gynandry 805-817 


CHAPTER     XXIII 

SYPHILIS 

Etiology — Immunity  against  Syphilis — Syphilitic  Reinfection — The  Con- 
tagion of  Syphilis — Methods  of  Contagion — Types  of  Syphilis — Periods 
of  Syphilis — The  Period  of  Primary  Incubation. — The  Period  of  Pri- 
mary Lesion — Induration — Location  of  the  Chancre. — The  Genital 
Chancre — Varieties  of  the  Genital  Chancre — Complications  of  Chancre 


CONTENTS.  XV 

PAGB 

— Diagnosis  of  Chancre — The  Differential  Diagnosis  of  Genital  Chancre 
— Concealed  Genital  Chancres — Chancre  of  the  Cervix  Uteri — Chancre 
of  the  Lip — Chancre  of  the  Tongue — Chancres  of  the  Extremities — 
Vaccination  Chancre — The  Prognosis  of  Chancre — Syphilitic  Lymphan- 
gitis and  Bubo — The  Period  of  Secondary  Incubation. 818-849 


CHAPTER     XXIV 

CONSTITUTIONAL  SYPHILIS — THE  SYPHILIDES SYPHILIS  OF  THE  ALIMENTARY  CANAL 

Syphilitic  Fever — Syphilitic  Neuralgia — Syphilides — Eruptions  on  the  Mu- 
cous Membranes — Syphilitic  Alopecia — Classification  of  Skin  Lesions — 
Erythematous  Syphilides — Papular  Syphilides — Conical  Papular  Syphi- 
lides— Flat  or  Lenticular  Papular  Syphilides — Moist  Papules — Papulo- 
squamous Syphilides — Vesicular  Syphilide — Pustular  Syphilide — Pig- 
mentary Syphilide — Tubercular  Syphilide — The  Bullous  Syphilide — 
The  Gummatous  Syphilide. — Syphilitic  Affections  of  the  Appendages 
of  the  Skin — Syphilitic  Alopecia  and  Onychia.— Syphilitic  Lesions  of 
the  Mucous  Membrane — Erythematous  Syphilide — Papular  Syphilide 
— Papulo-squamous  Syphilide — Gummata — Syphilis  of  the  Tongue — 
Syphilis  of  the  Gums — Syphilis  of  the  Palate — Syphilis  of  the  Pharynx 
— The  (Esophagus,  Stomach,  and  Intestines — The  Rectum  and  Anus .  .    849-903 


CHAPTER     XXV 

SYPHILIS  OF  THE  NEBVOUS  SYSTEM — OF  THE  EYE OF  THE  EAR OF  THE  BESPIEATOBY 

TRACT 

Cerebral  Syphilis  —  Etiology  —  Pathology  —  Symptomatology  —  Syphilitic 
Neuralgias — Headache  from  Bone-Lesions — Headaches  due  to  Syphi- 
litic AQ'ections  of  the  Brain  or  its  Envelopes — Prodromal  Cephalalgia 
of  Tertiary  Lesions — Parasyphilitic  Cephalalgia — Dia  •gnosis  of  Intra- 
cranial Syphilis. — Syphilis  of  the  Spinal  Cord — Syphilitic  Meningitis 
—  Acute  or  Subacute  Myelosypliiloses  —  Chronic  Myelosyphiloses  — 
Tabes  Dorsalis. — Syphilis  of  the  Nerves. — Syphilis  of  the  Eye — Syph- 
ilis of  the  Lachrymal  Apparatus — Syphilitic  Affections  of  the  Cornea 
— Syphilis  of  the  Sclera — Syphilis  of  the  Iris — Syphilis  of  the  Ciliary 
Body — Syphilis  of  the  Choroid,  Retina,  and  Optic  Nerve — Atrophy  of 
the  Optic  Nerve — Syphilitic  Palsies  of  the  External  Ocular  Muscles. — 
Syphilis  of  the  Ear. — Syphilis  of  the  Respiratory  Tract — Syphilis  of 
the  Nose — Syphilis  of  the  Nasal  Cavities — Acute  Syphilitic  Rhinitis — 
Hypertrophic  Rhinitis — Atrophic  Rhinitis — Gummata — Syphilis  of  the 
Larynx — Syphilis  of  the  Lungs 904-937 


CHAPTER     XXVI 

SYPHILIS  OF  THE  BONES  AND  JOINTS — OF  THE  MUSCLES OF  THE  HEART  AND  BLOOD- 
VESSELS  OF  THE  LYMPHATIC  SYSTEM OF  THE  LIVER — OF  THE  SPLEEN — OF  THE 

PANCREAS OF    THE    GENITO-UBINARY    ORGANS 

Osteoperiostitis — Rarefying   Ostitis — Gummatous   Periostitis,    Ostitis,   and 
Osteomyelitis — Osteosyphilosis   of    the    Cranium — The   Vertebrse — The 


Xvi  CONTENTS. 

PASB 

Tibia — The  Phalanges. — Syphilis  of  the  Joints — Arthralgia — Synovitis 
^Gummatous  Arthritis — Bursitis — Syphilis  of  the  Muscles — Acute 
Irritative  Myositis — Chronic  Interstitial  Myositis — Gummatous  Myo- 
sitis— Syphilitic  Tenosynovitis. — Syphilis  of  the  Circulatory  System 
'--Heart — ^Arteries — Veins. — Syphilis  of  the  Lymphatic  System. — 
Syphilis  of  the  Liver — Precocious  Syphilis  of  the  Liver — Tertiary 
Syphilis  of  the  Liver. — Syphilis  of  the  Spleen. — Syphilis  of  the  Pan- 
creas. —  Syphilis  of  the  Uro-Genital  System  —  The  Kidneys  —  The 
Ureters  and  the  Bladder — The  Epididymitis  and  Testicles — Syphilitic 
Epididymitis — Syphilitic  Orchitis — Syphilis  of  the  Vasa  Deferentia, 
Seminal  Vesicles,  Prostate,  Urethra,  and  Erectiles  Bodies  of  the  Penis. 
— Syphilis  of  the  Ovaries,  Uterus,  Vagina,  and  Vulva. — Syphilis  of 
-  the  Mammary  Gland. — The  Prognosis  of  Syphilis 938-968 


CHAPTER    XXVII 

SYPHILITIC   HEREDITY — HEREDITARY   SYPHILIS 

Descent  from  the  Father — Descent  from  the  Mother — ^Mixed  Heredity — 
Direct  Infection — The  Period  of  Syphilitic  Heredity — Conceptional 
Syphilis — Syphilis  and  Marriage — Prognosis  of  Syphilitic  Heredity. — 
Hereditary  Syphilis.  —  Skin  and  Mucous  Membrane  Lesions  of 
Hereditary  Syphilis — Erythematous  Syphilides — Papular  Syphilides 
and  Mucous  Patches — Vesicular  Syphilide — Pustular  Syphilide — Bul- 
lous Syphilide — Tubercular  and  Gummatous  Syphilides — The  Lesions 
of  the  Miicous  Membrane. — Hereditary  Syphilis  affecting  the  Eye. — 
Hereditary  Syphilis  affecting  the  Ear. — Hereditary  Syphilis  affect- 
ing the  Teeth. — Hereditary  Syphilis  affecting  the  Bones  and  Joints 
— The  Bones — Syphilitic  Dactylitis — The  Joints. — Hereditary  Syphilis 
affecting  the  Lymphatic  Glands. — Hereditary  Syphilis  affecting  the 
Nerve-Centres  and  Nerves — The  Brain — The  Spinal  Cord, — Heredi- 
tary Syphilis  affecting  the  Viscera — The  Lungs — The  Liver — The 
Spleen — The  Pancreas — The  Intestines — The  Kidneys. — Hereditary 
Syphilis  affecting  the  Testicles. — Diagnosis  of  Inherited  Syphilis — 
Early  Hereditary  Syphilis — Late  Hereditary  Syphilis 969-1000 


CHAPTER    XX  A"  III 

THE   TREATMENT   OF   SYPHILIS 

Prophylactic  Treatment.  —  The  Abortive  Treatment  —  Excision  or  Destruc- 
tion of  the  Chancre — Constitutional  Abortive  Treatment. — The  Con- 
stitutional Treatment  of  Syphilis — Interrupted  Treatment  of  Syphilis — 
Continuous  Treatment. — Systematic  Treatment  of  Syphilis — The  System- 
atic Treatment  by  Iodides— The  Toxic  Effects  of  Mercury— The  Toxic 
Effects  of  Iodides. — Methods  of  giving  Mercury — Mouth  Administration 
— Inunctions — Hypodermic  Injections — Vaporization — Mercuric  Baths, 
Thermal  Springs,  and  Heat — Electric  Baths — Intravenous  Injection  of 
Mercury — The  Elimination  of  Mercury — The  Use  of  Iodides  in  Syphilis 
— Zittmann's  Treatment  of  Intractable  Syphilis. — Local  Treatment  of 
Syphilis.— The  Treatment  of  Hereditary  Syphilis 1001-1051 


LIST  OF  ILLUSTRATIONS. 


PLATES. 

riGUBE  FAGB 

1.  Double  penis 5 

8.  Operation  for  phimosis 15 

9.  Operation  for  phimosis 15 

10.  Operation  for  phimosis 16 

11.  Operation  for  phimosis 16 

16.  Balanitis    31 

17.  Herpes  of  the  glans 31 

18.  Multiple  chancroids  of  the  coronary  sulcus   38 

19.  Chancroid  of  labium  major  38 

20.  Exulcerating  or  superficial  clianeroid 39' 

21.  Follicular  chancroid 39 

23.  Multiple  chancroids.      (Fox.)      Colored 42 

24.  Phagedenic  chancroid 42 

25.  Cliancroidal  bubo 42 

30.  Epithelioma,  ulcerating  form 64 

31.  Epithelioma,  vegetating  form 64 

54.  Acute  gonorrhosa.     Colored  114 

55.  Acute  pyogenic  urethritis.     Colored 114 

56.  Chronic  gonorrhoea.     Colored   114 

57.  Urinary  shred.     Colored    114 

66.  Gonorrhoeal  conjunctivitis.     Swelling  of  the  lids  and  free  discharge....    194 

67.  Gonorrhoeal   conjunctivitis.     Infiltration   of  bulbar   and   palpebral   con- 

junctiva   194 

103.  Hypertrophy  of  the  lateral  lobes  of  the  prostate.     (Watson.)    304 

114.  A.  Bacteriuria.     B.  Pyuria.     C.  Tubercle  bacilli  in  urine.     Colored....  352 

115.  Sediments  of  acid  and  alkaline  urine.     Colored 358 

122.  Male  and  female  ureter-cystoscopes 370' 

123.  1.  Aluminum    svs^ab    or    applicator.      2.  Urethral    tablet    depositor   and 

obturators.  3.  Aspirator.  4.  Inflating  bulbs  with  metal  extremity 
for  receiving  warm  air.  5.  Syringe.  6.  Funnel  with  tubing  for  irri- 
gating kidney  pelves   370 

124.  A.  Median  obstruction  in  prostatic  hypertrophy.     (Nitze.)     B.  Showing 

a  widespread  malignant  tumor  from  the  prostate.  (Nitze.)  C.  Vil- 
lous tumor  attached  to  the  bladder-wall.  (Nitze.)  D.  Shows  the 
stump  of  a  villous  tumor  which  has  sloughed  off.  (Nitze.)  E.  An 
air-bubble  which  was  carried  into  the  bladder  by  a  catheter. 
(Nitze.)     378 

125.  A.  A  cystoscopic  picture  of  the  normal  bladder,     (Nitze.)     B.  Ramifying 

vessels  on  the  bladder- wall.  (Nitze.)  O.  The  ureteral  orifice  on  a 
well-developed  ureteral  eminence.  (Nitze.)  D.  The  ureteral  papilla 
is  wanting.  (Nitze.)  E.  The  ureteral  papilla  immediately  before 
evacuation  of  the  urine.     (Nitze.)     i^.  Well-developed  ureteral  papilla. 

(Nitze.) 375 

xvii 


xviii  LIST  OF   ILLUSTKATIONS. 

FIGUBE  PAGB 

126.  Pictures  of  the  bladder-wall   and   internal   urethral   orifice  in  cases   of 

prostatic  hypertrophy.      (Nitze. )    378 

127.  Right  and  left  ureteral  orifices.      (Casper.)      Colored   378 

135.  Large  vesical  calculus.      (Pancoast.)    444 

142.  Opening  and  closing  the  blades  of  the  instrument  while  searching  for 

and  grasping  the  calculus 454 

143.  Crushing  a  small,  soft  calculus 454 

144.  Crushing  a  large,  hard  stone   454 

145.  Evacuating  fragments  after  the  calculus  has  been  crushed   454 

150.  A.  Normal   relations.     B.  Bladder   distended.      C  Bladder   and   rectum 

distended    • .  .  .   474 

151.  Vesical  calculus  almost  completely  filling  an  hypertrophied  bladder 475 

159.  Myxosarcoma.      ( Albarran. )    484 

160.  Lobulated  papilloma    (epithelial  cancer) .      (Albarran.)    488 

161.  Carcinoma    (epithelial  cancer) .      (Albarran.)    488 

169.  Multiple  calculi  in  the  ureter.      (Pancoast.)     516 

170.  Position  and  relation  of  the  kidneys  and  other  retroperitoneal  structures. 

Colored    524 

172.  Normal  kidney.      (BrOdel.) 526 

175.  Various  forms  of  kidney-stone,  illustrating  the  irregularities  in  shape. 

( Torres. )    550 

176.  Various  kinds  of  urinary  calculi.     Colored 550 

179.  Roentgen  ray  shadowgraph  showing  calculus  in  the  pelves  of  the  left 

kidney.    The  renal  artery  and  the  colon  are  also  shown 556 

180.  Calculus  impacted  in  first  portion  of  ureter.      (Pancoast.)    557 

192.  Showing   the   relations    and   coverings   of   the   testicle   and   epididymis. 

(Testut.)      Colored 616 

227.  Obstraction  by  the  median  portion  of  the  prostate 732 

228.  Separate  tumors  springing  from  the  lateral  lobes  of  the  prostate.     (Wat- 

son. ) 732 

229.  Bilateral  hypertrophy  of  the  prostate.     (Watson.) 732 

230.  Hypertrophy  of  the  median  lobe  of  the  prostate.    (Watson.) 732 

231.  Hypertrophy  of  median  and  one  lateral  lobe  of  prostate.     (Watson.). . . .  733 

232.  Bladder  and  prostate  cut  through  longitudinally  in  the  median  line 733 

255.  Chancre  of  the  reflected  layer 826 

256.  Chancre  of  the  meatus 826 

257.  Chancre  of  the  coronary  sulcus 827 

258.  Chancre  of  the  corona.     (Fox.)    Colored 828 

261.  Chancre  of  the  tongue.     (Fox.) 842 

262.  Chancre  of  the  tongue 843 

263.  Chancre  of  the  hand 843 

264.  Erythematous  syphilide.    (Fox.) 860 

265.  Flat  papular  syphilide 862 

266.  Acuminated  papular  syphilide.     (Fox.)    862 

267.  Acuminated  papular  syphilide.     (Fox.)    862 

268.  Large  flat  papular  syphilide.      ( Fox. )    863 

269.  Large  flat  papular  syphilide.      ( Fox. )    863 

270.  Large  flat  papular  syphilide 863 

271.  Vegetation  and  mucous  patches  about  the  vulva  863 

272.  Large  flat  papular  syphilide,  showing  scaling   863 

277.  Papulo-squamous  syphilide.      (Fox.)    866 


LIST  OF   ILLUSTRATIONS.  xix 

TIGURE  PAGE 

28 L  Papulo-squamous  syphilide  of  the  hand.     (Fox.)     Colored 868 

282.  Papulo-squamous  syphilide  of  the  palm.     (Fox.)      Colored 868 

283.  Papulo-squamous  syphilide  of  the  palm.      ( Fox. )      Colored    868 

284.  Large  pustular  syphilide.      (Fox.)    872 

285.  Pustulo-crustaceous  syphilide.      (Fox.)      Colored 872 

288.  Pustular  syphilide   (pustulo-crustaceous).     (Fox.)    874 

289.  Pustular  syphilide    (pustulo-crustaceous) .      (Fox.)    874 

290.  Flat  pustular  and  papulo-squamous  syphilide 875 

294.  Tubercular  syphilide.      (Fox.)      Colored   878 

297.  Ulcerating  tubercular  syphilide.      (Fox.)     Colored 878 

298.  Squamous  circinate  syphilide.      (Fox.)      Colored   878 

299.  Tubercular  syphilide.      ( Fox. )    880 

300.  Tubercular  syphilide.      (Fox.) ,  880 

301.  Syphilitic  rupia  following  the  bullous  syphilide 880 


FIGURES. 

2.  Application  of  forceps  in  circumcision 11 

3.  Appearance  after  first  cut  in  circumcision 11 

4.  Trimming  of  mucous  membrane  flaps  in  circumcision 11 

5.  Appearance  after  flaps  have  been  trimmed  in  circumcision 11 

6.  Insertion  of  flrst  and  second  sutures  in  circumcision   12 

7.  Operation  of  circumcision  completed   12 

12.  Paraphimosis 19 

13.  Reduction  of  paraphimosis 20 

14.  Reduction  of  paraphimosis    21 

15.  Osseous  growth  of  the  penis.      ( Demarquay. )    28 

22.  Indurated  elevated  chancroid   41 

26.  Chancroidal   phimosis    45 

27.  Chancroidal  ulceration  of  an  incision  for  relief  of  phimosis   54 

28.  Venereal  warts  on  the  penis   61 

29.  Epithelioma  of  the  penis   64 

32.  Epithelioma  of  the  penis  with  glandular  involvement   65 

33.  Cross-section  of  the  penis  showing  infiltration  of  epithelioma 65 

34.  Forms  of  penile  hypospadia   74 

35.  Peno-scrotal  hypospadia    75 

36.  Penis  straightened  after  transverse  cut  of  lower  surface  78 

37.  Transverse  wound  sutured  longitudinally:    glandular  urethra  formed.  . .  78 

38.  Freshened  areas,  incisions,  and  sutures  in  forming  glandular  urethra ...  78 

39.  Formation  of  penile  urethra    79 

40.  Formation  of  penile  urethra  completed   79 

41.  Glandular  epispadia.      (Kaufmann.)     81 

42.  Usual  form  of  epispadia 82 

43.  Formation  of  glandular  urethra.      (Thiersch.) 84 

44.  Outlining  of  flaps  to  form  penile  urethra 85 

45.  Flaps  for  forming  penile  urethra  folded  over  and  held  in  position   by 

sutures    85 


XX  LIST  OF  ILLUSTKATIONS. 

FIGURE  PAGE 

46.  1.  Transverse  defect  between  penile  and  glandular  urethras ;    2,  3,  oblique 

incision  through  foreskin.      (Thiersch.)    87 

47.  Foreskin  brought  up   behind  the  glans   and   sutures   uniting  freshened 

edges  of  foreskin   87 

48.  Closing  posterior  defect  in  epispadia   87 

49.  Suture  of  second  flap  87 

50.  Cured  epispadia.      ( Thiersch. )    88 

51.  Urethral  forceps    98 

52.  Urethral  calculi  showing  segmentation   99 

53.  Urethral  calculi  showing  mushroom  shape.     Cross-sections  lOD 

58.  Urethral  syringe    134 

59.  Irrigating  bag   138 

60.  Subacute  gonorrhoea;    pus;    epithelium;    mixed  infection.      (Guvon.)...  146 

61.  Instillator  for  the  posterior  urethra  159 

62.  Tommasoli's  ointment-carrier  162 

63.  Prostatic  dilator  163 

64.  Short  straight  bougie  172 

65.  Gonorrhoeal  phimosis    185 

68.  Gonorrhoeal  conjunctivitis  passing  into  a  panophthalmitis   195 

69.  Linear  strictures  of  the  urethra.     (Voillemier.)    207 

70.  Annular  stricture  of  the  urethra 208 

71.  Tortuous  stricture  of  the  urethra   208 

72.  Traumatic  stricture  of  the  urethra.      (Voillemier.)    212 

73.  Cast  of  the  urethra.     (Tetzel.)    219 

74.  Bougie  a  boule 220 

75.  Gauge  for  urethral  instruments 220 

76.  Filiform  bougies 228 

77.  Tunnelled  catheter.     Enlargement  of  tip  showing  position  of  tunnel ....  229 

78.  Steel  sound 229 

79.  Tip  of  catheter  just  entering  the  fixed  curve  of  the  urethra,     f  Antal)  .  .  .  231- 

80.  Fixed  urethral  curve   232 

81.  Fixed  curve  of  the  urethra  obliterated  by  the  passage  of  a  straight  in- 

strument.     (Antal.)     ; 232 

82.  Passing  a  sound 233 

83.  Passing  the  sound   234 

84.  Passing  the  sound  234 

85.  Passing  the  sound   235 

86.  Position  of  sound  after  passing  showing  tip  has  entered  bladder 235 

87.  Maisonneuve's  urethrotome   244 

88.  Teevan's  urethrotome   244 

89.  Gerster's  urethrotome    246 

90.  Teale's  probe-ended  gorget 247 

91.  Syme's  grooved  staff    248 

92.  Tunnelled  catheter  staff    248 

93.  Wheelhouse's   staff    251 

94.  Closure  of  fi.stula    2G8 

95.  Papilloma  of  the  urethra  270 

96.  Valentine's  endoscope   274 

97.  Chetwood's  urethroscope    275 

98.  Swinburne  urethroscope   275 

99.  Sterilizing-box  for  soft  urethral  instruments   282 


LIST  OF   ILLUSTEATIONS.  XXi 

FIGURE  PAGE 

100.  Tumor  formed  by  the  distended  bladder 296 

101.  Hypertrophied  bladder  from  urethral  stricture  299 

102.  Hypertrophy  of  the  lateral  and  median  lobes  of  the  prostate.      (Wat- 

son. )    305 

104.  Soft  rubber  catheter   307 

105.  Olivary  catheter 308 

106.  Conical  catheter 308 

107.  Elbowed  catheter 308 

108.  Double-elbowed  catheter 308 

109.  Cylindrical  catheter    308 

1 10.  Silver  probe  catheter   308 

111.  Soft  rubber  self-retaining  catheters 312 

112.  Securing  the  catheter  for  continuous  catheterization 313 

113.  Securing  the  catheter  for  continuous  catheterization 314 

116.  Aero-cystoscope    367 

117.  Cystoscope  with  the  light  and  window  on  the  outer  aspect  of  the  beak.  .  .  368 

118.  Catheterizing  cystoscope 369 

119.  Cabot's  catheterizing  cystoscope  369 

120.  Eisner's  catheterizing  cystoscope  370 

121.  Pryor's  cystoscope  for  the  female 370 

128.  Cathelin's  urine  separator 380 

129.  Cathelin's  urine  separator 381 

130.  Side  view  of  pelvic  viscera 388 

131.  Vesical  triangle.     (Sappey.)    390 

132.  A.  Day  urinal.     B.  Night  and  day  uriftal    394 

133.  Concentric  hypertrophy  of  the  bladder 398 

134.  Atony  of  the  bladder,  with  dilatation 400 

1 36.  Stone-searcher 446 

137.  Thompson's  stone-searcher   446 

138.  Bigelow's  lithotrite 452 

139.  Weiss's  lithotrite   452 

140.  Jaws  of  Bigelow's  lithotrite '. 453 

141.  Bigelow's  evacuator  and  tubes 454 

146.  Lithotomy   465 

147.  Grooved  lithotomy  staff 465 

148.  Stone  forceps   ( curved )    466 

149.  Calculus  scoop 466 

152.  Uric  acid  calculus.    Exact  size.    Weight,  nine  and  one-half  ounces.     Re- 

moved by  suprapubic  section 476 

153.  Another  view  of  same 476 

154.  Cushing's  suture  for  closing  the  bladder 477 

155.  Gibson's  method  of  closing  the  bladder   478 

156.  Gibson's  method  of  closing  the  bladder  479 

157.  Dawbarn's  method  of  suprapubic  bladder-drainage   480 

158.  Hook  for  extraction  of  hairpins  from  the  female  bladder 485 

162.  Thompson's  forceps  for  removing  vesical  tumors 493 

163.  Implantation  of  the  ureter  into  the  bowel  499 

164.  The  musculature  of  the  trigone.     (Young.)    505 

165.  End-to-end  anastomosis 509 

166.  End-in-side  anastomosis;    first  stage   509 

167.  End-in-side  anastomosis;    second  stage 510 


Xxii  LIST  OF   ILLUSTRATIONS. 

FIGURE  PAGE 

168.  End-in-side  anastomosis,  with  reinforcing  sutures  510 

171.  Renal  pelvis  dissected  from  the  pyramids.     (Henle. )    526 

173.  Proper  method  of  applying  corset  for  movable  kidney 534 

174.  Sustaining  sutures  for  fixing  the  kidney.     (Brodel.)    536 

177.  Multiple  bilateral  renal  cysts  and  calculi   551 

178.  Renal  calculus.     (Actual  size. )      (American  Text-Book  of  Surgery)    552 

181.  Lines  of  incision  for  operating  on  the  kidney  by  the  lumbar  route 561 

182.  Lateral  view  of  kidney  showing  line  of  incision.      (Brodel.)    562 

183.  The  proper  position  for  incision  of  the  kidney.     (Brodel.)    563 

184.  Method  of  suturing  split  kidney.      (Brodel.)    563. 

185.  Complete  destruction  of  kidney  by  an  abscess  578 

186.  Destruction  of  the  kidney  by  hydronephrosis 592 

187.  Large  vesical  calculus.    Contracted  hypertrophied  bladder,  double  hydro- 

nephrosis         592 

188.  Cyst  of  the  kidney 610 

189.  Large  cyst  of  the  kidney  6 10 

190.  Anatomy  of  the  left  testis.      ( Sappey. )    616 

191.  Anatomy  of  the  left  testis.      (Sappey.)    616 

193.  The  lobules  of  the  testis,  the  rete  vasculosum,  etc 618 

194.  The  efferent  canal  and  epididymis.     (Sappey.)    618 

195.  Dissection  showing  seminal  vesicles  and  ampullae  of  the  vasa  in  relation 

to  the  bladder  and  prostate  619 

196.  Elephantiasis  of  the  penis  and   scrotum,  showing  the  result   of  opera- 

tion       625 

197.  Diagram    showing   the    size    and   relative   position    of   the   testicle    and 

epididymis  in  acute  epididymitis.     (Kaufmann. )    646 

198.  Epididymitis  suspensory  bandage   , 649 

199.  Tubercular   epididymitis.      (Monod   and   Terrillon.)     660 

200.  Cancer  of  the  right  testicle.      (Monod  and  Terrillon.)    667 

201.  Intravaginal    spermatocele.      (Hochenegg. )     670 

202.  Encysted  hydrocele   671 

203.  Multilocular  cyst  of  the  epididymis.      (Monod  and  Terrillon.  i    671 

204.  Lymphadenoma  of  the  testicle  674 

205.  Vertical  section  of  hydrocele.      (Kocher.) 681 

206.  Hydrocele    682 

207.  Vertical  section  of  a  hydrocele.      (Kocher.)    684 

208.  Inguinal  hernia  with  hydrocele.      (Kocher.)    685 

209.  Inguinal  hernia  invaginating  the  upper  portion  of  the  sac  of  a  hydro- 

cele.     ( Kocher. )    686 

210.  Tapping  a  hydrocele 686 

211.  Bilocular  hydrocele.     (Beraud.)    (Kocher.) 688 

212.  Congenital  hydrocele  with  hernia 689 

213.  Inguinal  hernia,  with  hydrocele  of  the  cord.. 693 

214.  Lipoma  of  the  cord  (Pean) 703 

215.  Varicocele.     (Ofsborn.)    (Monod  and  Terrillon.) 704 

216.  Dilatation  of  veins  in  hydrocele.     (Kocher. ) 705 

217.  Eight  seminal  vesicle.    (Testut.) 708 

218.  Long  section  of  dilated  seminal  vesicle.     (Sappey.) 708 

219.  Deferent  canal  and  seminal  vesicle.    (Testut.) 709 

220.  Horizontal  section  of  the  bladder  and  seminal  vesicles.   (Testut.) 709 

221.  Relations  at  the  posterior  surface  of  the  bladder.    (Testut.) 710 


LIST  OF  ILLUSTRATIONS.  xxiii 

FIGURE  PAGE 

222.  Posterior  urethra  exposed  by  splitting  its  upper  wall.    (Testut.) 710 

223.  Vertical  section  of  pelvis.     (Testut. ) 719 

224.  Plexus  of  vessels  surrounding  the  prostate.    (Testut.) 720' 

225.  Ejaculatory  ducts,  seminal  vesicles,  etc.    (Murphy.) 721 

226.  Rectal  irrigator 727 

233.  Distorted  urethra  with  enlarged  prostate.     (Murphy.) 736 

234.  Prostatic  obstruction.     Effect  on  bladder  and  kidneys 737 

235.  Prostatic  obstruction  with  hypertrophy  of   the   bladder-wall  and   con- 

traction of  its  cavity 737 

236.  Chetwood's  galvano-cautery  prostatic  incisor 753 

237.  Various  perineal  incisions 757 

238.  Prostatectomy  through  retracted  edges  of  median  incision.     (Ferguson.)  758 

239.  Exposure    of    membranous  urethra    after   division  of    recto-urethritis. 

(Y  oung. ) 759 

240.  Opening  of  urethra  on  sound,  preparatory  to  introduction   of  tractor. 

(Young.) 759 

241.  Tractor  in  position,  blades  separated,  prostate  pulled  down,  posterior 

surface  exposed.    (Young.) 760 

242.  External  enucleation  begun.    (Young.) 761 

243.  Delivery  of  a  small  median  portion  into  lateral  cavity  by  use  of  finger 

instead  of  tractor.    (Young.) 761 

244.  Delivery  of  median  portion  into  lateral  cavity.     (Young.) 762 

245.  Young's  prostatic  tractor,  closed , 763 

246.  Young's  prostatic  tractor,  open 763 

247.  Young's  lobe  forceps 763 

248.  Mui-phy's  hooks  for  prostatectomy 764 

249.  Enucleation  of  lobes  of  prostate.     (Young.) 765 

250.  Suburethral  method  of  enucleating  median  bar.    (Young.) 765 

251.  Division    of  lateral    wall    of    urethra    for    removal    of    large    calculus. 

(Young.) 766 

252.  Perineal  drainage  after  prostatectomy.    (Ferguson) 767 

253.  Psychophore 790 

254.  Anastomosis  between   the  vas  deferens  and  the  head  of  the  epidid- 

ymis   803 

259.  Chancre  of  the  lip 839 

260.  Chancre  of  the  lip 840 

273.  Mucous  patches  of  the  lips 863 

274.  Mucous  patches  about  the  anus 863 

275.  Papular  syphilide,  showing  papillary  overgrowth 864 

276.  Syphilitic  vegetations 865 

278.  Papulo-squamous  syphilide 867 

279.  Papulo-squamous  syphilide.   (Fox) 867 

280.  Papulo-squamous  syphilide  of  the  hand.    (Fox) 868 

286.  Pustular  syphilide.    (Fox.) 873 

287.  Pustular  syphilide.   (Fox.) 874 

291.  large,  flat  pustular  syphilide.    (Fox.) 875 

292.  Serpiginous  syphilide.     (Fox.) 876 

293.  Non-ulcerating  tubercular  syphilide.    (Fox.) 878 

295.  Non-ulcerating  tubercular  syphilide.    (Fox.) 878 

296.  Tubercular  (squamous)  syphilide.     (Fox.)  — 879 

302.  Gummatous  syphilide.    (Fox) 882 


Xxiv  JUlST  OF   ILLUSTKATIONS. 

FIGURE  PAGE 

303.  Single  ulcerating  gumma 883 

304.  Ulcerating  gummata  becoming  confluent.      ( Fox. )    883 

305.  Multiple  gummata  of  the  leg.      ( Fox. )    884 

306.  Sloughing  gumma  of  the  leg   885 

307.  Ulcerating  gummata  of  the  malleolar  region.      (Fox.)    886 

308.  Syphilitic  alopecia  following  ulcerative  lesions.     (Fox.)    888 

309.  Gummatous  ulceration  destroying  the  nose.      (Fox.)    , 932 

310.  Skull  showing  the  results  of  gummatous  osteoperiostitis    940 

311.  Vault  of  the  cranium  exhibiting  the  results  of  gummatous  osteoperios- 

titis     941 

312.  Tubercular  and  gummatous  ulceration  of  hereditary  syphilis 979 

313.  Syphilitic  dactylitis   992 

314.  Hereditary  syphilis.     (De  Schweinitz.)    999 


GENITO-URINARY  DISEASES 


SYPHILIS. 


CHAPTER    I. 

DISEASES    AND    INJURIES    OF    THE    PENIS. 

Anatomy  of  the  Penis. — The  penis  in  size  bears  less  constant 
relation  to  general  physical  development  than  does  any  other  organ 
of  the  body.  Its  average  length  is  about  three  inches  when  in  the 
flaccid  condition  and  twice  that  when  erect ;  its  circumference  when 
it  is  flaccid  averages  about  three  inches.  It  is  made  up  in  the  main 
of  erectile  tissue.  This  is  separated  into  three  distinct  compartments 
by  investments  of  tough  fibrous  tissue.  The  bulk  of  the  penis  is 
formed  by  the  two  corpora  cavernosa  lying  side  by  side  and  capped 
by  the  glans,  which  is  a  continuation  of  the  corpus  spongiosum.  The 
corpus  spongiosum,  much  smaller  in  circumference  than  either  of  the 
cavernous  bodies,  lies  in  the  angle  formed  by  their  apposition,  bearing 
to  them  the  relation  that  a  ramrod  does  to  the  double  barrel  of  a  gun. 

The  cavernous  bodies  arise  from  the  tuberosity  and  ascending 
ramus  of  the  ischium  on  each  side,  and  pass  upward,  forward,  and 
inward  until  they  become  closely  apposed  to  each  other  beneath  the 
pubic  symphysis.  They  are  then  continued  forward,  each  in  a  flbro- 
elastic  sheath,  which  in  front  does  not  form  a  complete  partition 
between  the  two.  They  terminate  in  blunt  extremities,  which  are 
capped  by  the  glans. 

The  spongy  body — composed  of  erectile  tissue  and  also  invested 
by  a  fibro-elastic  sheath — is  made  up  of  a  central  portion  of  com- 
paratively small  diameter,  through  which  the  urethra  passes,  and  of 
two  terminal  expansions,  the  glans  penis,  capping  the  cavernous 
bodies,  and  the  bulb,  lying  in  the  angle  formed  by  the  two  convergent 
crura  of  the  cavernous  bodies,  and  attached  to  the  lower  surface  of 

1 


2  GENITO-UKINAEY    DISEASES   AND   SYPHILIS. 

the  triangular  ligament.  The  flange-like  expansion  at  the  base  of 
the  glans  is  termed  the  corona,  and  the  depression  behind  this  is 
called  the  cervix,  or  coronary  sulcus. 

In  addition  to  the  tough  fibro-elastic  sheath  with  which  the  spongy 
and  cavernous  bodies  are  each  supplied,  there  is  a  sheath,  termed 
Buck's  fascia,  or  the  fascia  of  the  penis,  which  binds  these  struc- 
tures together.  This  covers  in  the  two  rounded  extremities  of  the 
corpora  cavernosa  and  is  firmly  attached  to  the  base  of  the  glans 
penis.  Passing  backAvard  as  a  complete  investment  of  the  body  of 
the  penis,  it  is  continuous  with  the  suspensory  ligament  above  and 
with  the  deep  layer  of  the  superficial  fascia  below.  Superficial  to 
this  fascia  lies  an  extremely  loose  layer  of  areolar  tissue  without  fat, 
containing  a  thin  layer  of  muscular  fibres. 

The  thin  movable  skin  covering  the  penis  is  usually  continued 
forward  till  it  partly  or  completely  covers  the  glans ;  it  is  then 
doubled  back  upon  itself,  is  attached  to  the  cervix,  and  is  continued 
forward  over  the  glans  penis  till  it  joins  the  mucous  membrane  of  the 
urinary  meatus.  This  reduplication  is  termed  the  prepuce,  or  fore- 
skin. It  passes  forward  as  a  tough  fibrous  band,  called  the  frsenum, 
from  the  lower  central  part  of  the  coronary  sulcus  to  just  beneath 
the  urinary  meatus.  At  the  preputial  orifice  the  subcutaneous  layer 
is  especially  well  developed,  often  forming  a  tough  fibrous  ring.  The 
inner  surface  of  the  prepuce  and  the  covering  of  the  glans  penis  are 
moist,  thin,  and  more  like  mucous  membrane  than  like  ordinary  skin. 
On  the  flange-like  expansion  of  the  glans,  particularly  on  its  anterior 
aspect,  are  placed  the  glands  of  Tyson,  which  secrete  a  cheesy  sub- 
stance, termed  smegma ;  this,  when  it  undergoes  decomposition,  has 
a  characteristic  offensive  odor. 

The  suspensory  ligament  of  the  penis  is  a  strong,  triangular,  fibro- 
elastic  band  attached  to  the  front  of  the  pubic  symphysis  and  to  the 
two  cavernous  bodies  at  their  angle  of  junction. 

The  muscles  of  the  penis  are  the  erector  penis  or  ischio-cavernosus, 
the  accelerator  urinse  or  bulbo-cavernosus,  and  the  unstriped  muscular 
fibres  of  the  erectile  tissues  and  of  the  urethra. 

The  erector  penis  muscles  are  more  concerned  in  exercising 
pressure  upon  veins,  and  thus  increasing  turgescence,  than  in  me- 
chanically altering  the  position  of  the  penis.  They  arise  from  the 
ischiatic  tuberosities  and  are  inserted  in  the  lower  side  of  the  fibrous 
sheath  of  the  corpora  cavernosa. 

The  Dulbo-cavernosi  arise  from  the  central  perineal  point,  and, 
passing  upward  and  forward,  encircle  the  bulb  and  posterior  part  of 
the  spongy  body.     The  action  of  these  muscles  is  to  expel  by  theil 


DISEASES   AND   INJURIES  OF   THE   PENIS.  3 

contraction  the  last  drops  of  urine  and  to  drive  forward  with  force 
the  semen  when  it  passes  from  the  posterior  urethra. 

The  dorsal  arteries  of  the  penis,  two  in  number,  run  forward 
through  the  suspensory  ligament  on  each  side  of  the  dorsal  vein  to 
the  glans  and  prepuce,  also  giving  branches  to  the  cavernous  bodies. 
The  arteries  of  the  corpora  cavernosa  give  the  main  blood-supply  to 
the  erectile  tissue  of  the  cavernous  bodies.  The  artery  of  the  bulb 
gives  the  main  blood-supply  to  the  corpus  spongiosum.  All  these 
vessels  are  derived  from  the  internal  pudic.  In  addition,  there  is  a 
collateral  supply  due  to  an  anastomosis  of  the  same  vessels  with 
branches  of  the  external  pudic. 

The  dorsal  vein  of  the  penis  is  the  largest  efferent  vessel  of  this 
organ ;  it  passes  backward  in  a  groove  on  the  dorsum  of  the  penis 
through  the  suspensory  ligament  and  into  the  prostatic  plexus ;  the 
smaller  veins  nearly  all  pass  backward,  pouring  their  blood  into  the 
same  plexus. 

The  nerves  of  the  penis  are  derived  from  the  internal  pudic  (the 
dorsal  nerve  of  the  penis)  and  from  the  hypogastric  plexus  (nervi 
erigentes  to  the  erectile  tissue). 

The  lymphatics  pass  partly  to  the  inguinal  region,  particularly 
those  of  the  glans,  the  foreskin,  the  surface  of  the  penis,  and  the  an- 
terior part  of  the  urethra,  partly  to  the  deep  pelvic  lymphatic  system. 

The  tensile  strength  of  the  penis,  because  of  its  tough  fibrous  in- 
vestments, is  sufficient  to  bear  the  entire  weight  of  the  body.  The 
fibrous  investment  of  the  blunt  extremities  of  the  two  cavernous 
bodies  where  they  are  capped  by  the  glans  delays,  and  sometimes 
prevents,  the  backward  extension  of  inflammatory  or  infiltrating 
processes,  particularly  cancerous  infiltration,  which  primarily  involve 
the  glans.  This  fibrous  sheath,  being  a  continuation  of  the  deep  layer 
of  the  superficial  fascia,  also  limits  the  forward  extension  of  urinary 
and  purulent  infiltrations  beneath  this  fascia,  such  infiltrations  sparing 
the  glans. 

The  free  blood-supply  to  the  penis  and  the  rich  innervation  of  the 
organ  insure  rapid  healing  in  case  of  wounds,  and  justify  conservative 
treatment  even  though  it  has  been  nearly  severed  or  extensively 
crushed. 

The  lymphatic  vessels,  passing  as  they  do  to  the  inguinal  glands 
and  to  the  glands  of  the  pelvis,  carry  infection  in  both  directions : 
hence,  for  instance,  in  case  of  malignant  disease  with  involvement  of 
the  glands  of  the  groin,  removal  of  the  disease  together  with  the 
enlarged  inguinal  glands  gives  no  assurance  against  deep  recurrence 
of  the  growth. 


4  GENITO-UEINAPvY   DISEASES   AND   SYPHILIS. 

The  lax  vascular  subcutaneous  tissue  readily  becomes  osdematous 
either  from  local  or  from  general  causes,  especially  in  the  region  of 
the  foreskin. 

The  delicate  richly  innervated  skin  is  extremely  sensitive  to  irri- 
tants. 

Anomalies  of  the  Penis  are  rarely  observed  unassociated 
with  other  malformations.  A  large  percentage  of  those  thus  afflicted 
are  mentally  deficient.  The  penis  may  be  absent,  concealed,  minute, 
gigantic,  double,  twisted,  or  adherent. 

Absence  of  the  ?enis. — Harris  has  collected  eight  cases  of  this 
anomaly,  unassociated  with  other  deformities,  the  testes  being  normal. 
In  one  case  the  urethra  opened  into  the  perineum,  in  the  others  just 
within  the  anal  sphincter.  Demarquay  quotes  the  case  of  a  patient 
who  had  reached  the  ag-e  of  twenty-seven  when  he  sought  medical 
advice  for  the  relief  of  an  acute  orchitis.  The  urethra  opened  into 
the  anus,  and  there  was  in  the  perineum,  just  anterior  to  the  anus, 
a  small  wart-like  projection  of  erectile  tissue.  Venereal  excitement 
caused  this  tissue  to  become  turgid,  and,  if  sufficiently  prolonged,  was 
followed  by  escape  of  semen  through  the  urethra. 

Concealed  Penis. — Absence  of  the  penis  may  be  seeming  only, 
the  organ  being  concealed  beneath  the  surface.  In  one  such  case  an 
incision  freed  the  organ  and  enabled  the  infant,  who  was  suffering 
from  retention  of  urine,  to  pass  his  water. 

Ireatment  of  the  malformation  is  usually  unnecessary,  since  con- 
comitant deformities  will  first  require  care.  When,  however,  there 
is  a  chance  for  survival,  opportunity  should  be  taken  to  search  thor- 
oughly for  a  concealed  rudimentary  penis.  This,  if  found,  should  be 
dissected  free,  and,  by  plastic  operation,  covered  with  integument 
derived  from  the  surrounding  parts. 

Micropenis. — Arrested  growth  of  an  otherwise  perfectly  formed 
penis  is  by  no  means  uncommon,  though  this  rarely  produces  results 
so  marked  that  the  condition  may  be  properly  termed  anomalous. 
In  general  terms  it  may  be  stated  that  a  flaccid  adult  penis  less  than 
two  inches  in  circumference  and  two  and  a  half  inches  in  length  is 
abnormal,  though  even  in  such  a  case  the  erectile  tissue  may  be 
dilatable  to  an  unusual  degree,  thus  making  the  organ  normal  in 
size  when  in  a  condition  of  physiological  activity.  In  some  reported 
cases  the  penis  has  varied  in  size  from  that  of  a  quill  to  that  of  the 
last  two  joints  of  the  little  finger. 

As  seen  in  adults,  stunting  of  the  penis  is  perhaps  more  com- 
monly due  to  excessive  masturbation  or  to  other  causes  interfering 
with  development  than  to  congenital  defect. 


Fig.  1. 


Double  penis. 


DISEASES   AND   INJUKIES  OP   THE    PENIS.  5 

Treatment. — A  minute  penis  when  observed  at  birth  or  shortly 
after  does  not  require  treatment,  except  for  the  relief  of  preputial 
adhesions  or  of  tight  phimosis,  since  the  organ,  as  is  the  case  with 
the  testicles,  may  before  puberty,  or  about  this  time,  grow  rapidly  and 
attain  normal  dimensions.  A  tight  foreskin  should  be  removed,  and 
any  abnormal  condition  interfering  with  local  growth  should  be  reme- 
died. 

When  the  condition  is  observed  soon  after  puberty  or  in  the  young 
adult  the  prospect  for  ultimate  growth  is  by  no  means  hopeless.  In 
these  cases  physiological  activity  of  the  part  is  at  times  followed  by  a 
rapid  growth  till  normal  size  is  reached. 

For  the  purpose  of  developing  a  stunted  penis  a  suction  apparatus 
has  been  employed.  The  penis  is  slipped  into  a  large  cylinder  fitting 
closely  around  the  root  of  the  organ ;  from  this  cyhnder  the  air  is 
partly  exhausted  by  means  of  a  rubber  bulb.  This  causes  congestion, 
distention  of  the  erectile  tissue,  and,  it  is  asserted,  permanent  enlarge- 
ment. Such  a  treatment  to  be  efficient  would  have  to  be  long  con- 
tinued. 

Megalopenis, — As  has  already  been  observed,  the  size  of  the  organ 
bears  no  constant  relation  to  the  size  or  strength  of  the  individual. 
In  congenital  imbeciles  it  is  often  of  unusual  size,  and  in  dwarfs  and 
hunchbacks  it  is  not  uncommonly  developed  not  only  out  of  propor- 
tion to  the  other  parts  of  the  organism,  but  even  beyond  the  average 
for  individuals  of  normal  growth.  Hypertrophy  of  the  penis  is  at 
times  an  inconvenience,  and  may  even  be  a  source  of  danger,  since 
an  excessive  development  predisposes  to  abrasions  and  fissures 
through  which  inoculation  with  venereal  diseases  may  occur. 

There  is  no  surgical  treatment  for  this  affection,  though  by  me- 
chanical appliances  the  interference  with  function  may  be  partly  or 
completely  obviated.  ^ 

Double  Penis. — A  few  authentic  cases  illustrative  of  this  anomaly 
have  been  reported.  The  two  organs  are  usually  placed  side  by  side, 
and  there  are  other  evidences  of  monstrosity  by  fusion.  In  at  least 
two  reported  cases  each  organ  was  functionally  perfect.  (Fig.  1.) 

Surgical  treatment  is  not  indicated. 

Torsion  of  the  Penis,  or  a  twisting  of  the  penis  on  its  long  axis  so 
that  the  fraenum  looks  forward,  is  extremely  rare,  unless  hypospadia 
or  other  malformation  is  present.  Urination  and  ejaculation  of  the 
semen  are  not  materially  interfered  with :  hence  treatment  would  be 
indicated  only  from  a  cosmetic  stand-point. 

Adherent  Penis. — Rarely,  as  an  isolated  anomaly,  the  penis  is  found 
adherent  to  the  scrotum  through  nearly  its  whole  extent.     This  ma- 


6  GENITO-UEIlSrAKY   DISEASES   AND   SYPHILIS. 

terially  interferes  with  function,  and,  when  the  penis  is  of  normal  size 
and  not  incurved,  should  be  operated  on  as  soon  as  it  is  discovered. 

The  treatment  consists  in  cutting  through  the  skin  attachment  of 
the  penis  till  the  organ  is  entirely  freed,  providing  for  the  closure  of 
the  raw  surface  by  a  plastic  operation  where  necessary. 

Anomalies  of  the  Prepuce. — The  foreskin  may  be  absent,  in- 
completely developed,  redundant,  or  adherent  to  the  glans  ;  the  pre- 
putial orifice  may  be  absent  or  extremely  small ;  the  frsenum  may  be 
abnormally  short. 

Absence  or  incomplete  development  requires  no  treatment,  nor 
does  redundancy  urgently  demand  surgical  intervention,  except  where 
it  is  complicated  with  phimosis  and  an  irritated  or  inflammatory  con- 
dition of  the  glans. 

Adhesions  between  the  glans  and  the  inner  surface  of  the  prepuce 
are  present  in  the  majority  of  infants.  At  times  such  adhesions  are 
the  result  of  a  balanoposthitis ;  they  are  usually  congenital,  and  are 
generally  associated  with  phimosis. 

Adhesions  may  appear  in  the  form  of  comparatively  narrow  bridles 
or  bands,  or  may  involve  broad  areas.  Commonly  the  symphysis  is 
limited  to  the  corona,  and  is  so  tight  that  in  the  operation  for  circum- 
cision the  line  of  adhesion  is  frequently  taken  for  the  normal  line 
along  which  the  mucous  membrane  is  reflected  behind  the  glans,  and 
thus  the  coronary  sulcus  is  not  freed  of  the  retained  smegma  usually 
found  here  in  such  cases.  Exceptionally  the  whole  surface  of  the 
glans  adheres  to  the  foreskin,  the  lips  of  the  meatus  alone  being  free. 
Adhesions  between  the  foreskin  and  the  glans  sometimes  act  as  a 
source  of  reflex  irritation,  causing  nervous  phenomena  of  a  convulsive 
or  paralytic  type.  This  is,  however,  very  exceptional,  and  probably 
never  occurs  except  when  there  are  distinct  local  signs  of  irritation. 
Children  in  whom  the  adhesions  are  tightest  and  most  extensive  com- 
monly exhibit  a  penis  much  below  the  average  size.  In  the  adult  such 
adhesions,  at  least  as  congenital  deformities,  are  rare,  since  the  bond 
of  union  is  easily  torn  by  slight  mechanical  interference.  Occasion- 
ally the  bands  are  so  tough  that  nothing  short  of  an  operation  can 
strip  them. 

The  treatment  of  adhesions  between  the  glans  and  the  foreskin  is 
in  ordinary  cases  readily  carried  out.  Phimosis  having  been  relieved, 
either  by  stretching  the  preputial  orifice  or  by  circumcision,  the  ad- 
hesions between  the  two  mucous  surfaces  of  the  foreskin  and  the 
glans  can  be  stripped  back  by  firm  sponging,  or  by  the  pressure  of 
the  thumb-nail,  or  by  blunt  dissection,  using  the  flat  end  of  a  probe 
for  this  purpose.     Sometimes  rough  handling  is  necessary  before  the 


DISEASES   AND   INJUKIES  OF   THE    PENIS.  7 

adhesions  yield.  The  stripping  back  should  be  continued  till  the 
coronary  sulcus  is  freed  through  its  whole  extent,  usually  exposing 
a  ring  of  smegma.  The  raw  surfaces  resulting  from  this  stripping 
should  be  well  coated  with  boric  ointment  (acid,  boric,  si ;  ung. 
petrol,  carbolat,  si),  when  the  prepuce  can  be  drawn  forward  again 
if  circumcision  has  not  been  performed.  Twice  daily  the  raw  surfaces 
should  be  exposed,  washed  with  a  mild  antiseptic,  and  protected  by 
boric  ointment.  In  a  week  or  ten  days  heahng  will  be  complete. 
This  stripping  operation  should  be  conducted  with  ordinary  anti- 
septic precautions,  since  death  from  cellulitis  has  more  than  once 
resulted  when  such  precautions  were  neglected.  Firm  fibrous  adhe- 
sions require  the  use  of  the  knife. 

Obliteration  or  occlusion  of  the  preputial  orifice  may  not  be  de- 
tected directly  after  birth,  but  cannot  long  escape  attention,  since 
failure  to  pass  water  and  the  formation  of  a  tumor  at  the  end  of  the 
penis,  due  to  distention  of  the  preputial  sac  with  urine,  are  certain  to 
be  noticed.  Demarquay,  however,  reports  a  case  of  four  months' 
standing  with  a  prepuce  distended  to  the  size  of  a  bladder. 

The  treatment  is  circumcision. 

Narrowing  of  the  Preputial  Orifice — Phimosis. — The  term 
phimosis  implies  that  the  preputial  orifice  is  so  narrowed  that  the 
foreskin  cannot  be  retracted  behind  the  glans.  The  orifice  may  be  so 
small  that  a  probe  will  pass  with  difficulty.  Phimosis  may  be  tem- 
porary or  permanent.  In  the  former  case  it  is  due  to  inflammatory 
swelling  or  infiltration ;  in  the  latter,  to  congenital  formation,  or  new 
growth,  or  cicatricial  contraction. 

Congenital  Phimosis. — This  condition  is  present  in  the  great  ma- 
jority of  male  infants  at  birth,  and  persists  up  to  the  fifth  or  seventh 
year,  at  which  time  there  usually  takes  place  distinct  enlargement  of 
the  preputial  orifice,  so  that  the  foreskin  can  be  stripped  back  without 
much  difficulty. 

Phimosis  when  moderate  in  degree  and  not  giving  rise  to  obstruc- 
tion or  inflammation  occasions  no  symptoms.  Its  complications  are, 
however,  distressing,  and  sometimes  cause  permanent  impairment  of 
health. 

The  complications  of  phimosis  are : 

1.  Those  due  to  local  irritation:  i.e.,  balanitis,  balanoposthitis, 
adhesions,  venereal  warts,  fissures. 

2.  Those  due  to  obstruction :  subpreputial  calcuh,  retained  secre- 
tion, irritability  of  the  bladder,  hemorrhoids,  hernia,  and  dilatation  of 
the  bladder,  of  the  ureters,  and  of  the  kidney  pelves. 

3.  Those  due  to  reflex  action :  retention  or  incontinence  of  urine, 


8  GENITO-URINAEY    DISEASES   AND   SYPHILIS. 

arrested  development  of  the  penis,  precocious  sexualism,  seminal 
weakness,  spastic  palsies,  simulated  hip-joint  disease,  muscular  inco- 
ordination, convulsions,  coUc,  indigestion,  night  terrors. 

Balanitis  and  balanoposthitis  are  caused  by  the  decomposition  of 
the  fev^  drops  of  urine  retained  in  the  preputial  sac.  This  inflamma- 
tion in  its  turn  often  gives  rise  to  warts,  fissures,  or  adhesions. 

As  the  opening  becomes  narrower  through  continued  irritation, 
the  salts  of  the  urine  are  deposited  and  calculi  may  be  formed.  If  at 
each  act  of  micturition  the  prepuce  "  balloons,"  an  unusual  strain  is 
thrown  on  the  bladder,  which  becomes  irritable. 

The  varied  reflexes  owe  their  existence  to  the  exceedingly  rich 
nerve-supply  of  the  part.  When  there  are  distinct  evidences  of  local 
irritation  associated  with  symptoms  of  general  nerve  disturbance,  the 
possibility  of  a  relation  between  the  latter  and  the  phimosis  must  be 
carefully  weighed.  This  by  no  means  impHes  that  a  phimosis  which 
excites  no  local  symptoms  can  be  regarded  as  surely  the  exciting 
cause  of  otherwise  inexpKcable  nerve-storms. 

Acquired  Phimosis,  when  permanent,  i.e.,  cicatricial,  differs  from 
the  congenital  form  in  that  the  redundant  skin  lying  in  front  of  the 
preputial  orifice  is  usually  wanting,  and  the  latter  is  felt  as  a  more  or 
less  irregularly  indurated  band  or  circle,  which  instead  of  rolling  back 
on  attempts  at  retraction  slowly  stretches,  tightly  embracing  the 
glans. 

When  temporary,  acquired  phimosis  is  due  to  swelling,  usually 
inflammatory  or  congestive. 

Treatment. — Permanent  phimosis,  whether  congenital  or  acquired, 
should  be  treated  by  operation  whenever  it  is  responsible  for  local  or 
reflex  symptoms.  As  a  prophylactic  against  gonorrhoea,  chancroid, 
chancre,  and  cancer,  the  operation  is  desirable,  even  when  the  con- 
dition excites  no  trouble.  The  treatment  of  temporary  phimosis  due 
to  inflammatory  swelling  wifl  be  described  when  considering  the 
various  affections  which  may  produce  this  condition. 

The  operation  of  choice  in  phimosis  is  circumcision.  Incision  of 
the  foreskin  or  stripping  back  will  also  reheve  the  condition. 

Stripping  back  is  applicable  only  in  the  congenital  form  of  phimosis. 
It  is  possible  in  most  cases.  It  is  accomplished  first  by  making  the 
body  of  the  penis  as  prominent  as  possible.  Slight  manipulation  is 
in  children  usually  followed  by  erection.  Whether  this  occurs  or  not, 
the  skin  is  pulled  back  as  far  as  possible  towards  the  root  of  the  penis, 
this  organ,  when  it  is  sufficiently  developed,  being  made  prominent 
and  held  in  place  by  the  ring  and  middle  fingers  of  each  hand,  first 
pressed  in  deeply  towards  the  subpubic  angle,  then  brought  together 


DISEASES   AND    INJURIES    OF   THE    PENIS.  9 

SO  that  the  root  of  the  penis  is  grasped  firmly  and  steadied  between 
their  tips  while  subsequent  manipulations  with  the  foreskin  are  con- 
ducted with  the  thumb  and  index  finger  of  each  hand.  These  ma- 
nipulations consist  in  stripping  back  and  tearing  adhesions  with  the 
thumb-nails  or  in  forcible  sponging  on  the  part  of  an  assistant  or 
in  blunt  dissection  with  a  probe  or  grooved  director.  The  stripping 
must  be  continued  till  the  ring  of  smegma  is  exposed  and  cleaned  out. 
The  raw  surfaces  are  then  washed  with  weak  bichloride  solution  (1  to 
6000),  dried,  well  greased  with  boric  ointment,  and  the  foreskin  drawn 
forward.  The  foreskin  must  be  retracted  for  washing  and  dressing 
daily  for  ten  to  fourteen  days.  Nor  is  it  safe  to  intrust  this  treat- 
ment to  the  mother,  since,  when  the  preputial  ring  is  tight,  phimosis 
may  be  converted  into  what  is  for  her  an  irreducible  paraphimosis. 

Circumcision. — This  operation  is  indicated  in  every  case  of  phi- 
mosis in  children,  not  only  because  it  prevents  the  various  compli- 
cations of  a  tight  foreskin,  which  may  interfere  with  growth  and 
general  nutrition,  but  also  because  it  does  away  with  the  suggestion 
to  masturbation  which  the  irritation  of  a  tight  foreskin  often  gives. 

In  very  young  children  the  operation  of  circumcision  is  much  more 
difficult  than  it  is  in  adults.  The  parts  are  small  and  the  tissues  soft 
and  non-resisting.  The  previous  adhesions  are  usually  tight,  so  that 
the  glans  is  abraded  from  stripping.  The  application  of  dressings 
which  may  reasonably  be  expected  to  remain  in  place  requires  much, 
manual  dexterity.  It  is  in  infants  mainly  that  the  fault  of  taking  off" 
too  much  skin  has  been  committed.  This  is  avoided  by  marking  the 
position  of  the  corona  with  a  blue  pencil  before  beginning  the  oper- 
ation. The  most  frequent  error  is  failure  to  strip  adhesions  until 
the  coronary  sulcus  is  free  and  its  contained  ring  of  smegma  is  ex- 
posed. This  leads  to  recurrent  phimosis  and  usually  to  an  entire 
failure  to  accomplish  the  object  for  which  the  operation  was  under- 
taken. 

In  the  absence  of  phimosis  circumcision  is  also  indicated  where 
there  is  a  tendency  to  the  formation  of  venereal  Avarts,  to  prolonged 
attacks  of  balanoposthitis,  to  recurrent  herpes  progenitalis,  to  fissur- 
ings  and  erosions  during  intercourse,  to  hypersecretion  on  the  part  of 
Tyson's  glands,  to  sexual  erethism  without  evident  cause,  to  appar- 
ently causeless  functional  disturbances  of  the  bladder,  such  as  nocturnal 
enuresis,  and  to  masturbation. 

In  preparing  for  operation  the  parts  are  thoroughly  washed  with 
hot  soapsuds,  the  preputial  sac  being  cleaned  by  means  of  injections 
of  1  to  40  carbolic  in  1  to  4000  sublimate  solution.  The  ordinary 
antiseptic  precautions  are  observed.     The  penis  is  passed  through  a 


10  GENITO-UPvINARY   DISEASES   AND   SYPHILIS. 

small  opening  made  in  the  centre  of  a  sterilized  towel,  and  the  latter 
is  then  spread  out,  thus  preventing  the  wound  surfaces  from  coming 
in  contact  with  the  skin  which  has  not  been  cleansed.  The  instru- 
ments required  are  a  pair  of  fenestrated  circumcision  forceps,  although 
the  fenestra  is  not  necessary,  a  knife  sharpened  to  a  razor  edge,  a  pair 
of  scissors  which  cut  on  the  points,  haemostats,  a  pair  of  dissecting 
forceps,  and  small  straight  needles. 

Infants  and  young  children  should  be  given  a  general  anaesthetic. 
Adults  whose  prepuces  can  be  so  retracted  that  the  mucous  surfaces 
can  be  infiltrated  before  incision  can  be  operated  on  painlessly  under 
local  anaesthesia.     The  solution  to  be  employed  is  as  follows : 

li    CocainEe  hydrochloratis  or  eucaine,  gr.  i  ; 
Sodii  chloridi,  gr.  iii  ; 
Adrenalin  chlorid  (1  :  1000),  ttlxxx  ; 
Aquai  destillatfe,  f^^i. 

The  syringe  being  filled  with  the  solution,  the  needle  is  driven  into 
but  not  through  the  skin,  and  two  drops  are  injected,  raising  a  white 
bleb.  The  needle  is  then  thrust  in  the  line  of  proposed  incision  be- 
yond the  border  of  the  first  bleb  about  a  sixth  of  an  inch,  and  two 
drops  are  again  injected  ;  this  is  continued  from  the  mid-dorsal  region 
till  the  fii'aenum  is  reached,  the  injections  being  made  into  and  not 
beneath  the  skin.  The  other  semi-circumference  of  skin  is  similarly 
treated.  Then  the  foreskin  is  retracted  and  its  inner  layer  is  in- 
jected in  the  same  way,  the  blebs  again  being  formed  along  the  pro- 
posed line  of  incision.  Finally,  the  loose  tissue  lying  between  the 
skin-layers  is  infiltrated,  when  the  operation  can  be  performed  with- 
out causing  the  slightest  pain.  The  objection  to  this  method  of  anaes- 
thesia lies  in  the  fact  that  the  necessary  infiltration  interferes  with  neat 
coaptation,  and  where  the  foreskin  cannot  be  retracted  it  is  difficult  to 
anaesthetize  the  inner  layer. 

The  phimosis  forceps  are  applied  loosely  to  the  foreskin,  as  it  lies 
naturally  so  that  the  fenestra  is  placed  just  over  the  prominent  ridge 
of  the  corona  and  with  its  long  axis  parallel  to  this  ridge, — that  is, 
from  above  downward  and  from  behind  forward.  Maintaining  the 
forceps  in  their  relative  position  to  the  skin  surface  by  light  pressure, 
the  end  of  the  prepuce  is  drawn  forward  and  the  forceps  are  gently 
closed,  thus  pressing  the  glans  penis  behind  them.  (Fig.  2.)  As  soon 
as  the  operator  is  sure  that  the  glans  is  entirely  behind  the  forceps 
they  are  closed  firmly,  and  the  prepuce  is  divided  by  carrying  the 
knife  along  the  fenestra.  On  releasing  the  forceps  the  skin  at  once 
retracts  behind  the  corona,  leaving  the  glans  still  covered  with  the 


DISEASES    AND    INJURIES   OF   THE    PENIS. 


11 


mucous  membrane  ;  a  band  of  integument  often  remains  about  the 
preputial  orifice.  (Fig.  3.)  One  blade  of  a  pair  of  scissors  is  slipped 
within  the  latter,  care  being  taken  that  the  meatus  is  not  entered, 
and  the  prepuce  is  split  along  the  dorsum  to  within  one-sixth  of  an 

Fig.  3. 


Application  of  forceps. 


Appearance  after  first  cut. 


inch  of  its  reflection  from  the  coronary  sulcus.  This  part  of  the 
operation  is  sometimes  difficult,  on  account  of  adhesions.  These 
should  be  thoroughly  stripped,  as  already  described.  The  mucous 
membrane  having  been  thus  split  and  stripped,  each  flap  of  it  is 


Fig.  4 


Fk;.  5. 


Trimming  of  mucous  membrane  flaps.  Appearance  after  flaps  have 

been  trimmed. 

drawn  away  from  the  penis  and  trimmed  off  by  means  of  the  scis- 
sors (Fig.  4),  leaving  a  circular  band  of  mucous  membrane  one-sixth 
of  an  inch  in  width  passing  completely  around  behind  the  corona. 
Bleeding  points  are  seized  in  the  artery  forceps  and  either  twisted  or 
ligated  with  the  finest  catgut.     By  the  oblique  incision  just  described 


12 


GENITO-URIXAEY   DISEASES   AND   SYPHILIS. 


the  fraenal  arteries  frequently  are  not  divided.  Where  there  is  great 
redundancy  of  tissue  in  this  region,  there  sliould  be  no  hesitation  in 
removing  it.  When  the  frsenal  arteries  are  cut,  it  is  safest  to  tie 
them.  If  the  operation  has  been  properly  planned,  the  apposition 
between  the  edges  of  the  divided  skin  and  the  remaining  strip  of 
mucous  membrane  will  be  almost  perfect,  so  that  very  few  sutures 
will  be  required.  (Fig.  5.)  The  sutures  employed  should  be  of  fine 
silk,  threaded  on  small  straight  needles.  In  infants,  fine  non-chromi- 
cized  catgut  is  best,  since  this  does  not  require  removal. 

The  first  suture  should  be  applied  at  the  fraenum.     It  includes  a 


Fig.  6. 


Fig.  7. 


Insertion  of  first  and  second  sutures. 


Operation  completed. 


narrow  strip  of  the  skin  at  the  position  of  the  raphe,  and  should  take 
a  fairly  deep  grip  on  the  tissues  of  the  frgenum.  As  it  is  tightened, 
care  must  be  taken  that  the  skin  is  not  inverted.  This  cannot  well 
happen  if  the  needle  is  inserted  near  its  cut  edge.  The  next  stitch 
is  inserted  in  the  mid-dorsal  region.  (Fig.  6.)  A  stitch  on  either  side 
midway  between  the  two  already  described  is  often  sufficient,  though 
in  adults  it  is  safer  to  apply  a  complete  row  of  sutures,  since  the  irri- 
tation incident  to  the  operation  often  occasions  erection,  which  may 
tear  loose  the  feeble  adhesions  formed  in  the  first  few  hours.  (Fig.  7.) 
The  dressing  may  be  either  dry  or  wet.  In  the  dry  dressing  the 
line  of  incision  is  dusted  with  iodoform  or  acetanilid,  then  covered  with 
a  thin  narrow  strip  of  sterile  gauze,  and  o^-er  this  is  painted /rcs/i  iodo- 
form collodion.  In  using  this  dressing,  which  is  applicable  only  to  such 
cases  as  are  likely  to  heal  by  first  intention, — i.e.,  those  operated 
upon  under  circumstances  most  favorable  for  the  observance  of  rigid 
asepsis  and  not  complicated  by  pre^dous  inflammation, — the  strip  of 
dry  sterile  gauze  first  applied  to  the  wound  must  extend  to  but  not 


DISEASES   AND    INJUEIES   OF   THE    PENIS.  13 

across  the  coronaiy  sulcus.  This  is  then  secured  in  place  by  painting 
on  sufficient  collodion  to  make  an  occlusion  dressing.  The  penis  is  then 
wrapped  in  absorbent  cotton,  and  bandaged  in  the  erect  position  against 
the  pubis  and  lower  belly  surface  either  by  the  crossed  of  the  perineum 
or  the  "jock-strap,"  and  the  patient  is  allowed  to  be  up  and  about. 

The  wet  dressing  Avill  in  the  long  run  give  the  most  satisfactory 
results.  A  narrow  strip  of  lint  or  gauze  sixteen  inches  long,  split  at 
one  end,  is  dipped  into  an  antiseptic  solution  (phenol  sodique  one 
part,  water  five  parts,  or  boroglyceride,  twenty-five  per  cent.,  one 
part,  water  three  parts),  and  secured  in  place  by  tying  the  split  ends. 
This  dressing  is  kept  wet  by  the  antiseptic  solution,  which  is  dropped 
on  at  short  intervals.  In  children  it  is  maintained  in  place  by  the 
pressure  of  the  diaper.  The  latter  should  be  perfectly  clean,  since 
the  wet  strip  is  liable  to  drop  off  and  thus  allow  of  wound  infection. 
Plealing  should  take  place  by  first  intention  in  from  four  to  seven  days. 
The  stitches  can  be  removed  on  the  fifth  day,  and  after  that  the  line  of 
incision  may  be  dressed  with  a  narrow  strip  of  lint  coated  with  a  thick 
layer  of  boric  ointment  and  held  in  place  by  adhesive  plaster,  or  the 
dressing  may  be  of  gauze  and  collodion. 

Instead  of  the  wet  dressing  an  ointment  may  be  used,  and  this  is 
particularly  serviceable  when  extensive  stripping  has  left  the  glans 
raw  and  sensitive  and  readily  adhering  to  any  fabric,  such  as  gauze, 
which  is  brought  in  immediate  contact  with  it.  After  the  operation 
is  completed  a  T-bandage  is  applied,  with  the  T  in  front  and  an 
opening  properly  placed  in  the  vertical  strip  below  the  waistband  to 
admit  the  penis.  A  piece  of  lint  backed  by  a  piece  of  thin  gutta- 
percha is  cut  in  the  shape  of  a  Maltese  cross,  with  a  perforation  in  the 
centre  for  the  meatus  urinarius,  and  of  such  size  that  the  limbs  of  the 
cross,  when  the  meatus  is  placed  at  this  opening,  reach  to  the  peno- 
scrotal junction.  The  gutta-percha  tissue  and  lint  are  basted  together. 
The  lint  side  is  then  thickly  spread  with  recently  sterilized  boric  oint- 
ment, and  closely  applied  to  the  penis.  Finally,  a  gauze  bandage 
holds  the  dressing  in  place  and  is  secured  to  the  T  by  safety-pins. 
This  dressing  should  be  changed  two  or  three  times  a  day,  or  other- 
wise it  will  become  dry  and  adherent. 

The  complications  of  circumcision  at  the  time  of  operation  are 
hemorrhage  and  oedematous  swelling  of  the  loose  cellular  tissue,  par- 
ticularly that  near  the  freenum. 

Hemorrhage  is  easily  controlled  by  the  forceps.  They  should  pick 
up  the  bleeding  vessels  with  as  little  surrounding  tissue  as  possible, 
and  every  bleeding  point  should  be  secured.  The  oedematous  in- 
filtration readily  subsides  in  the  after-treatment  under  the  use  of 


14  GElSriTO-UEINARY   DISEASES   AND   SYPHILIS. 

cold  evaporating  lotions.  This  rapid  osdema  is  troublesome  mainly 
because  it  interferes  with  coaptation ;  sometimes  as  many  as  twenty 
or  thirty  sutures  are  required  before  the  cut  edges  can  be  brought 
together  accurately  around  the  entire  line  of  incision.  In  such  cases 
it  is  well  to  employ  the  continuous  suture,  interrupting  it  after  four 
or  five  stitches  have  been  taken.  Thus  the  neatest  apposition  may 
be  secured  in  even  the  most  troublesome  cases. 

Consecutive  hemorrhage  from  the  frsenal  arteries  is  sometimes 
severe.  When  these  arteries  have  not  been  tied,  a  moderately  tight 
bandage  should  be  applied,  and  directions  should  be  given  the  nurse 
to  watch  for  either  rapid  swelling  and  discoloration  of  the  penis  or 
external  bleeding.  When  the  line  of  suture  has  been  tight,  the 
blood  may  be  extravasated  into  the  cellular  tissue,  causing  enormous 
swelling,  and,  in  case  of  concomitant  infection,  extensive  sloughing. 

The  treatment  consists  in  opening  the  wound,  securing  the  bleed- 
ing vessels,  and  evacuating  as  much  of  the  clot  as  possible.  Evapo- 
rating and  antiseptic  lotions,  such  as  lead  water  and  alcohol,  subse- 
quently may  be  applied. 

(Edematous  swelling  coming  on  after  the  operation  is  completed  is 
usually  dependent  upon  bleeding,  though  it  sometimes  develops  when 
haemostasis  has  been  absolute.  It  is  commonly  due  to  the  use  of 
irritant  antiseptics,  though  it  may  occur  without  assignable  cause.  It 
subsides,  in  part  at  least,  in  from  one  to  two  days  under  elevation, 
the"  application  of  evaporating  lotions,  and  the  administration  of  a 
brisk  purgative.  It  often  persists  for  months  in  the  form  of  a  semi- 
solid oedema  about  the  fraenum.  In  nearly  all  cases  this  disfiguring 
swelling  ultimately  disappears  entirely.  This  may  be  hastened  by 
the  application  of  stimulating  and  absorbent  ointments,  such  as  thyol 
or  ichthyol  ten  parts,  and  lanolin  one  hundred  parts. 

Infection. — When  through  a  lack  of  care  in  antiseptic  precaution, 
or  because  of  operation  on  previously  infected  tissues,  the  wound  be- 
comes infected,  swelling  is  rapid  and  extensive,  and  all  the  symptoms 
of  local  inflammation  are  marked.  Under  these  circumstances  it  is 
best  to  provide  for  drainage  by  the  removal  of  stitches  where  the  line 
of  suture  has  been  tight.  The  infected  tissue  should  be  washed  with 
hydrogen  peroxide,  followed  by  bichloride  1  to  2000,  or  carbolic  1  to 
40,  solutions,  and  should  be  wrapped  in  an  antiseptic  and  cooling 
wet  dressing,  unless  the  inflammation  is  of  such  high  grade  that  the 
vitality  of  the  parts  is  threatened.  In  this  case  large  hot  antiseptic 
fomentations  are  indicated,  together  with  treatment  appropriate  to 
acute  inflammation.  This  complication  of  phimosis  is  rarely  encoun- 
tered, except  when  the  operation  is  performed  during  the  course 


Fig.  8. 


The  appearance  of  the  penis  in  a  case  of  phimosis. 
Fig.  9. 


A  grooved  director  is  introduced  beneath  the  prepuce  in  the  median  line  on  the  dorsal  surface. 


Fig.  10. 


A  knife  is  passed  along  the  grooved  director  and  its  point  brought  out  ready  to  split  the  prepuce  in 

the  median  line. 

Fig.  11. 


The  skin  and  mucous  membrane  have  been  trimmed  off  with  scissors  and  the  first  two  sutures 
nave  been  introduced,  one  at  the  frsenum  and  the  other  in  the  median  line  of  the  dorsal  surface  of 
the  penis. 


DISEASES    AND   INJURIES   OF   THE   PENIS.  17 

of  an  acute  inflammatory  attack.  Under  such  circumstances  cir- 
cumcision should  not  be  undertaken  unless  the  indications  for  it  are 
imperative. 

Interference  with  Erection. — This  results  from  the  removal  of  too 
much  skin.  The  operator  may  fail  to  notice  the  relations  betv^^een  the 
skin  surface  and  the  deeper  parts,  but,  seizing  the  prepuce  and  draw- 
ing it  forward  as  far  as  possible,  may  apply  his  phimosis  forceps,  make 
his  cut,  and  find  that  he  has  denuded  the  penis  almost  as  far  back  as 
the  scrotal  junction.  In  this  case,  after  healing  marked  distortion  or 
incurvation  of  the  penis  may  for  a  time  occur  on  erection ;  but,  owing 
to  the  great  extensibility  of  the  skin,  the  ultimate  prognosis  is  good ; 
at  times  the  frsenum  will  require  division. 

Beeurrence  of  the  Phimosis. — When  too  much  of  the  mucous  layer 
of  the  foreskin  has  been  left,  phimosis  may  recur  in  a  more  severe 
form  than  that  for  which  the  original  operation  was  undertaken,  the 
cicatricial  tissue  along  the  line  of  suturing  sometimes  contracting  very 
rapidly.  A  strip  of  mucous  membrane  wider  than  a  fourth  of  an 
inch  should  never  be  left.  If  narrower  than  a  sixth  of  an  inch,  it  is 
somewhat  difficult  to  insert  the  sutures  satisfactorily. 

A  method  of  performing  circumcision,  popular  because  of  its  sim- 
plicity, requires  simply  scissors,  curved  bistoury,  grooved  director, 
artery  forceps,  and  needle  and  thread.  The  grooved  director  is 
passed  through  the  preputial  orifice  back  to  the  coronary  sulcus. 
It  is  moved  from  side  to  side  to  make  sure  that  it  has  not  entered  the 
meatus,  palpation  with  the  fingers  showing  that  its  extremity  passes 
over  the  surface  of  the  glans  and  does  not  cause  this  body  to  follow 
its  motions.  The  curved  bistoury  is  passed  along  the  groove  of  the 
director,  and  its  point  is  brought  out  through  the  dorsum  of  the 
prepuce.  By  cutting  forward  and  upward  with  the  knife  the  prepuce 
and  its  mucous  layer  are  split.  By  means  of  the  scissors  one  of  the 
tabs  of  skin  and  mucous  membrane  is  trimmed  downward  and  for- 
ward to  the  meatus,  leaving  a  width  of  not  over  one-sixth  of  an  inch 
of  mucous  membrane.  The  other  tab  is  trimmed  off  in  the  same 
manner,  and  sutures  are  apphed.     (See  Figs.  8,  9,  10,  11.) 

This  operation  has  the  advantage  of  removing  skin  and  mucous 
membrane  together  and  dispensing  with  the  phimosis  forceps.  It  is 
the  method  of  choice  in  those  cases  of  inflammatory  swelling  and 
exudation  in  which  the  prepuce  cannot  be  drawn  forward  and  the 
fenestrated  forceps  cannot  be  apphed. 

Paraphimosis. — When  the  prepuce  has  been  retracted  behind  the 
glans  and  cannot  again  be  brought  forward,  the  condition  is  termed 
paraphimosis.     The  exciting  cause  is  usuafiy  a  more  or  less  forcible 

2 


18  GENITO-UEINAET   DISEASES  AND   SYPHILIS. 

retraction  of  a  tight  foreskin,  though  occasionally  inflammatory  swell- 
ing will  cause  the  foreskin  to  roll  back. 

In  gonorrhoea,  chancroid,  chancre,  balanoposthitis,  and  all  lesions 
of  the  genitalia  attended  by  swelling  of  the  glans  or  the  foreskin,  this 
complication  is  particularly  liable  to  occur.  It  is  most  frequently 
observed  in  children  as  a  result  of  manipulation  of  the  parts. 

When  a  narrow  preputial  orifice  is  drawn  behind  the  corona  the 
constriction  it  exerts  upon  the  parts  causes  rapid  swelling.  The  glans 
becomes  markedly  enlarged  and  glossy.  It  is  often  partially  concealed 
by  a  thick  collar  of  shiny  oedematous  mucous  membrane,  behind 
which  there  is  a  deep  excoriated  sulcus,  and  back  of  this  sulcus  there 
is  usually  a  second  oedematous  band  less  marked  than  the  one  lying 
immediately  behind  the  coronary  sulcus.  The  penis  seems  to  have  a 
distinct  upward  kink  or  bend  just  behind  the  glans.  This  appear- 
ance is  due  to  the  deep  notch  caused  by  the  margin  of  the  retroverted 
preputial  orifice  of  the  penis,  and  to  the  oedematous  swelhng  which  is 
particularly  marked  about  the  position  of  the  fraenum.  In  some 
cases,  where  the  tense  inelastic  edge  of  the  orifice  exerts  a  more  than 
usual  amount  of  constriction,  circulation  is  markedly  interfered  with, 
and  ulceration  and  even  sloughing  involving  both  the  foreskin  and 
the  head  of  the  penis  may  take  place.  This  comphcation  would  un- 
doubtedly be  more  frequent  were  it  not  for  the  rich  blood-supply  to 
the  glans  and  the  anastomosis  between  its  vessels  and  those  of  the 
corpora  cavernosa.    The  ulceration  usually  involves  the  foreskin  only. 

When  the  swelhng  consequent  upon  paraphimosis  is  well  devel- 
oped (Fig.  12)  there  is  encountered  first  a  furrow  (a),  the  coronary 
sulcus,  which  is  normally  found  behind  the  corona ;  in  these  cases  it 
appears  deeper  because  it  is  intensified  by  the  oedematous  swelhng. 
Covering  this  furrow,  and  even  overlapping  the  glans  somewhat,  is  a 
shiny  oedematous  cohar  of  mucous  membrane  (6).  This  is  that  por- 
tion of  the  prepuce  which  is  normally  in  contact  with  the  posterior 
face  and  border  of  the  corona.  Behind  this  swollen  fold  is  found  a 
second  deep,  often  ulcerated  furrow  (c) ;  this  is  the  actual  seat  of 
constriction,  and  behind  it  is  placed  yet  another  ridge  of  swollen 
integument  (d). 

Paraphimosis  is  attended  with  very  severe  pain,  which  does  not 
intermit  until  the  constriction  has  been  reheved,  either  by  operation 
or  by  the  process  of  ulceration.  Where  surgical  interference  is  de- 
layed, or  has  not  been  successful  in  remedying  the  trouble,  the  subse- 
quent cicatricial  contraction  may  occasion  great  deformity. 

Treatment. — The  treatment  of  paraphimosis  is,  of  course,  reduc- 
tion.    This  should  be  effected  at  once,  except  in  those  cases  where 


DISEASES    AND   INJUKIES   OF    THE    PENIS. 


19 


paraphimosis  is  the  result  of  a  previously  existing  inflammation  and 
is  not  occasioning  sufficient  interference  with  circulation  seriously  to 
complicate  the  original  lesion.  For  instance,  patients  with  a  short 
foreskin  suffering  from  chancroid  frequently  have  the  foreskin  rolled 
back,  and,  as  a  consequence  of  oedema  following  the  original  lesion, 
cannot  bring  it  forward  again.  In  such  cases  the  paraphimosis  is  a 
result,  not  a  cause,  and  frequently  occasions  no  circulatory  disturb- 
ance. Treatment  of  the  original  lesion,  together  with  evaporating 
lotions,  rest,  and  elevation  of  the  part,  will  bring  about  a  cure.  All 
such  cases  should,  however,  be  carefully  watched,  and  should  be 
operated  on  at  the  first  sign  of  strangulation. 

When  paraphimosis  is  of  sudden  development  and  not  dependent 
upon  cedema  consequent  upon  a  pre-existing  lesion,  it  should  be 

Fig.  12. 


ParaphimosLs. 


reduced  at  once,  whether  symptoms  of  strangulation  are  present  or 
absent.  If  the  glans  penis  is  purple,  black,  or  mottled  in  color,  cold, 
and  non-sensitive,  the  indications  for  interference  are  still  more 
urgent.  Here  no  time  should  be  lost  in  efforts  at  reduction  by  me- 
chanical means.  The  constricting  band  should  be  divided,  the  fore- 
skin drawn  forward,  and  the  vitality  of  the  parts  restored  as  far  as 
possible  by  the  long-continued  application  of  hot  compresses  wrung 
out  in  mild  antiseptic  lotions  and  changed  every  few  minutes. 


20  GENITO-UKINAET   DISEASES   AND   SYPHILIS. 

Reduction  is  easily  accomplished  if  the  case  is  seen  before  oedema 
has  become  very  marked.  When  there  is  no  fear  for  the  vitality  of 
the  part,  an  ice-bag  may  be  applied  to  the  penis  for  half  an  hour. 
Ether  should  then  be  administered,  the  thick  oedematous  collar,  the 
greatest  obstacle  to  reduction,  should  be  punctured  in  many  places 
by  means  of  an  ordinary  surgical  needle,  and  the  anterior  and  inner 
surface  of  this  collar  and  the  corona  glandis  should  be  lubricated 
with  carbohzed  oil.  The  surgeon  then  seizes  the  penis  just  behind 
the  seat  of  constriction  between  the  lateral  surfaces  of  the  middle 
and  ring  fingers  of  both  hands,  and  while  the  two  thumbs  and  index 
fingers  press  upon  the  glans  penis,  not  pushing  it  backward,  but 
squeezing  it  and  drawing  it  slightly  forward,  the  fingers  endeavor  to 
draw  the   prepuce   over  the   thus   narrowed   and   elongated   glans. 

Fig.  18. 


Reduction  of  piaraphimosis. 

(Fig.  13.)  Backward  pressure  with  the  thumbs  has  the  effect  of 
making  the  base  of  the  glans  broader,  and  thus  effectually  prevents 
reduction. 

Reduction  may  also  be  effected  by  grasping  the  penis  in  the  left 
hand,  as  in  seizing  a  rope,  the  thumb  and  forefinger  being  applied 
behind  the  seat  of  constriction.  The  fingers  and  the  thumb  of  the 
right  hand  are  applied  to  the  glans  penis,  which  is  compressed  later- 
ally and  drawn  slightly  forward,  while  an  effort  is  made  to  carry  the 
strictured  part  cle?r  of  the  corona  glandis  by  exerting  traction  with 
the  left  hand.     (Fig.  14.) 

When  these  manipulations  fail,  a  rubber  band  may  be  wound 
about  the  glans,  covering  it  in  completely  from  before  backward. 
This  so  reduces  the  glans  in  size  that  the  end  of  a  grooved  director 


DISEASES   AND   INJURIES   OF   THE    PENIS. 


21 


or  the  handle  end  of  a  scalpel  can  usually  be  passed  beneath  the 
constricting  band.  When  that  is  accomplished  the  rubber  band  is 
removed,  and  by  means  of  the  instrument  introduced  beneath  the 
constriction  reduction  is  readily  effected. 

When  these  measures  prove  unsuccessful,  the  constriction  must 
be  divided.  This  can  be  done  by  pulling  the  collar  of  oedematous 
mucous  membrane  downward  towards  the  glans  as  far  as  possible, 
thus  exposing  the  constricting  band,  which  is  divided  in  one  or  more 
places  by  a  sharp  scalpel.     It 

must  be  borne  in  mind  that  -        *''*^-  ^'^• 

the  constriction  usually  lies 
behind  the  oedematous  collar 
of  mucous  membrane  which 
covers  and  conceals  the  coro- 
nary sulcus. 

Exceptionally,  when  the 
prepuce  is  merely  retracted 
instead  of  being  rolled  back, 
and  slips  up  without  turning 
over,  the  preputial  ring  grasps 
the  penis  immediately  behind 
the  corona.  This  may  be 
compared  to  pulling  up  a 
tight  coat-sleeve  instead  of 
turning  it  up.  If  in  such  a 
case  there  be  sufficient  con- 
striction to  occasion  strangu- 
lation, the  thick  collar  of  oedematous  mucous  membrane  will  be 
wanting,  and  the  constricting  band  will  lie  in  the  coronary  sulcus, 
where  it  can  readily  be  divided  by  inserting  beneath  it  a  grooved 
director,  guided  by  which  an  incision  with  a  curved  bistoury  can  be 
made. 

The  incision  must  be  sufficiently  free  to  allow  of  easy  reduction. 
Sometimes  where  enough  time  has  elapsed  for  the  formation  of  in- 
flammatory adhesions  two  or  three  incisions  are  necessary. 

Pieduction  should  be  complete.  In  cases  of  marked  oedema  after 
prolonged  manipulation,  the  congested  fold  of  mucous  membrane  may 
be  pulled  completely  over  the  glans,  simulating  reduction  when  in 
reality  this  has  not  been  effected.  This  is  particularly  the  case  in 
children  who,  if  unanaesthetized,  by  their  struggles  prevent  the  sur- 
geon from  appreciating  the  distinct  and  sudden  slip  which  denotes 
reduction.     When  the  paraphimosis  is  properly  reduced  the  glans 


Reduction  of  paraphimosis. 


22  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

disappears  entirely  and  can  be  exposed  only  by  forcibly  drawing  the 
foreskin  backward. 

Under  certain  circumstances  the  surgeon  may  be  compelled  to 
resort  to  palliative  measures.  The  fears  of  a  patient,  in  the  case  of  a 
child  the  anxiety  of  parents,  or  the  comparative  mildness  of  symptoms, 
may  justify  the  application  of  pressure.  This  may  be  appMed  by 
means  of  adhesive  straps  or  by  a  bandage.  Straps,  if  used,  should  be 
narrow  and  so  applied  that  uniform  pressure  is  exerted.  The  resin 
plaster  should  be  employed.  The  penis  is  completely  covered  in  by 
strips  placed  longitudinally,  the  first  running  from  the  middle  of  the 
upper  surface  of  the  organ  to  the  middle  of  the  under  surface,  and  the 
others  being  applied  so  that  each  overlaps  its  predecessor.  Then  cir- 
cular straps  are  applied,  running  from  the  extremity  of  the  penis  back- 
ward, the  meatus  being  left  free.  In  a  day  there  is  usually  sufficient 
diminution  of  swelling  to  permit  reduction. 

After  incision  and  reduction  the  parts  should  be  wrapped  in  a 
bandage  kept  continually  wet  with  dilute  lead  water,  or  with  phenol 
sodique  and  water  equal  parts,  or  with  lead  water  and  alcohol,  till  the 
swelling  subsides,  when  the  wound  may  be  dressed  with  powdered 
iodoform  or  boric  acid  ointment. 

Solid  oedema  of  the  foreskin  sometimes  persists  for  weeks  or 
months.  In  this  case  circumcision  is  advisable,  though  the  persistent 
use  of  pressure,  supplemented  by  applications  of  ichthyol  ointment 
(ten  per  cent.),  will  ultimately  cause  the  disappearance  of  the  swelling. 

Shortness  of  the  Frsenum. — This  congenital  deformity  in  cer- 
tain cases  interferes  with  complete  erection  of  the  glans,  turning  the 
orifice  of  the  meatus  downward,  and  not  only  preventing  ejaculation 
in  the  proper  direction,  but  also  rendering  sexual  intercourse  painful, 
or  even  impossible. 

The  treatment  is  simple  and  efficient.  The  frsenum  is  put  upon 
the  stretch,  a  narrow  bistoury  is  thrust  through  its  base,  and  by  an 
incision  from  within  outward  the  bridle  of  skin  is  cut  completely 
through.     The  prepuce  is  kept  retracted  until  the  healing  is  com.plete. 

INJURIES   OF   THE    PENIS. 

Contusion. — This  implies  an  injury  by  crushing  force  without 
lesion  of  the  skin.  The  phenomena  attendant  upon  such  an  injury  do 
not  differ  from  those  following  similar  traumatisms  in  other  parts  of 
the  body.  Owing  to  the  looseness  of  the  cellular  tissue,  ecchymosis 
and  oedema  are  often  so  pronounced  as  to  simulate  rapid  gangrene. 

When  the  vessels  of  the  cavernous  bodies  are  involved  there  is 
free  subcutaneous  bleeding,  giving  rise  to  a  circumscribed  fluctuating 


DISEASES   AND   INJURIES   OF    THE    PENIS.  23 

tumor,  most  prominent  during  erection.  This  tumor  is  somewhat 
slow  in  forming,  and  occasionally  suppurates.  Under  conservative 
treatment  it  usually  disappears.  When  injury  has  not  only  oc- 
casioned extensive  extravasation  of  blood,  but  has  lacerated  the 
urethral  canal,  the  inflammatory  phenomena  observed  after  rupture 
of  the  urethra  quickly  develop.  (See  page  91.)  Moreover,  there  is 
Immediately  bleeding  from  the  meatus,  which  should  lead  to  prompt 
diagnosis  and  appropriate  treatment. 

Treatment. — The  treatment  of  contusions  of  the  penis  is  conducted 
on  general  principles, — rest,  elevation,  pressure  by  narrow  gauze 
bandages,  the  application  of  evaporating  lotions,  and,  for  the  purpose 
of  hastening  absorption,  gentle  massage. 

Extensive  swelling  and  discoloration  need  not  occasion  anxiety, 
unless  there  has  been  rupture  of  the  spongy  or  cavernous  bodies  or 
of  the  urethra.  When  gangrene  is  threatened  on  account  of  the 
severity  of  the  lesion  or  because  of  interference  with  circulation  oc- 
casioned by  the  pressure  of  effused  blood,  hot  antiseptic  fomenta- 
tions frequently  repeated  are  indicated.  These  dressings  are  made 
by  wringing  fifteen  or  twenty  layers  of  antiseptic  gauze  out  of  a 
hot  1  to  10,000  bichloride  solution.  They  may  be  covered  with 
waxed  paper  to  prevent  evaporation.  If  the  symptoms  are  still 
progressive,  free  incision  and  ligation  of  bleeding  vessels,  followed 
by  suture  of  the  wound,  are  indicated.  Emphysema  is  always  a 
serious  symptom,  and  usually  calls  for  free  incision,  as  it  probably 
results  from  infection  with  saprophytic  organisms  in  addition  to  those 
of  suppuration. 

On  the  first  sign  of  suppuration  after  contusion,  incision  should  be 
made  sufficiently  free  to  secure  thorough  drainage. 

Wounds  of  the  Penis. — These  are  classified  according  to  gen- 
eral surgical  principles  as  incised,  lacerated,  punctured,  and  contused. 

Incised  wounds,  if  superficial,  are  readily  closed,  and  heal  quickly. 
Deep  wounds,  that  is,  those  involving  the  erectile  tissue,  bleed  freely, 
and,  if  transverse  and  extensive,  are  liable  to  be  followed  by  loss  of 
erectile  power  in  the  tissue  lying  anterior  to  the  wound.  When  the 
penis  is  completely  divided,  hemorrhage  is  so  rapid  that,  unless  it  is 
promptly  arrested,  a  fatal  issue  is  probable. 

Treatment. — The  treatment  of  these  wounds  is  conducted  on  gen- 
eral principles.  Violent  hemorrhage  is  checked  by  ligatures :  the  sur- 
faces are  brought  in  apposition  and  held  there  by  sutures  passed 
through  the  fibrous  sheath  of  the  erectile  tissue,  but  no  deeper.  This 
simple  fixation  is  usually  sufficient  to  stop  the  venous  oozing.  If  not, 
a  stiff  English  catheter  is  passed  into  the  urethra,  and  a  pressure 


24  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

bandage  is  applied  for  some  hoars.  Inflammatory  reaction  always 
excites  erection.  This  interferes  with  primary  healing,  and  should  be 
prevented  by  full  doses  of  bromide  (.^iii  daily),  by  opium  and  bella- 
donna suppositories,  or  by  hypodermics  of  morphine.  Even  if  the 
penis  is  almost  completely  severed,  hanging  by  a  small  strip  of  tissue, 
an  effort  should  be  made  to  suture  it  in  place.  When  the  penis  is 
completely  cut  off,  the  bleeding  vessels  are  tied,  the  cavernous  bodies 
are  covered  in  by  suture  of  their  fibrous  envelopes,  the  skin  is  drawn 
forward  and  sewed  over  the  closed  ends  of  the  corpora  cavernosa, 
and  the  urethra  is  split  and  secured  to  the  skin  to  prevent  subsequent 
stricturing  of  its  orifice.     (See  page  66.) 

When  the  urethra  is  divided  it  should  be  sutured,  and  the  urine 
should  be  drawn  by  a  small  soft  catheter.  Intermittent  catheteriza- 
tion is  practised  for  five  days,  the  instrument  at  each  passing  being 
attached  to  a  fountain  syringe  and  being  introduced  with  a.stream  of 
protargol  (1  to  2000)  flowing  through  it.  After  the  bladder  is  emptied^ 
the  fountain  syringe  is  again  attached  to  the  catheter,  and  as  the  latter 
is  withdrawn  the  anterior  urethra  receives  another  antiseptic  washing. 
When  the  introduction  of  the  soft  catheter  is  excessively  painful, 
continuous  catheterization  should  be  practised.  (See  page  311  et 
seq.)  If,  as  a  result  of  cicatrization  following  wounds,  erection  is 
complete  but  there  is  deviation  of  the  penis  from  a  straight  line,  cure 
by  operation  may  be  successful.  When,  however,  there  has  been  ob- 
literation or  obstruction  of  the  spaces  of  the  spongy  and  cavernous 
bodies,  producing  deviations  and  incomplete  erections,  treatment  is 
unavailing. 

Punctured  wounds  of  the  penis,  when  inflammatory  symptoms  are 
pronounced  and  infection  is  probable,  should  be  converted  into 
incised  wounds,  cleansed,  and  drained  from  the  bottom. 

Contused  and  lacerated  avounds  of  the  penis  are  particularly  dan- 
gerous only  when  the  urethra  is  involved  or  the  injury  is  so  great  as 
to  devitalize  tissues.  When  extensive  they  are  liable  to  be  followed 
by  imperfect  erection  or  by  distortion  of  the  penis.  The  treatment 
consists  in  subduing  inflammatory  phenomena.  Bleeding  in  these 
cases  is  moderate  ;  when  the  urethra  is  involved  permanent  catheter- 
ization is  practised.  Sometimes  the  catheter  cannot  be  introduced 
till  the  urethra  is  opened  behind  the  seat  of  injury,  and  then  the  posi- 
tion of  its  proximal  end  in  the  wound  is  determined  by  passing  an 
instrument  from  behind  forward. 

Gun-shot  wounds  of  the  penis  partake  of  the  nature  of  contused 
and  lacerated  wounds,  are  subject  to  the  same  complications,  and 
require  similar  treatment.     The  shot  or  bullets,  if  embedded  in  the 


DISEASES   AND    INJUKIES   OP   THE   PENIS.  25 

erectile  tissue,  should  always  be  removed,  and  every  possible  portion 
of  the  penis  should  be  preserved. 

Fracture  of  the  Penis. — This  injury,  possible  in  a  literal  sense 
only  when  the  penis  has  undergone  calcification,  occurs  when  during- 
vigorous  erection  the  organ  is  subjected  to  a  sudden  twist  or  bend. 
The  cause  of  the  injury  is  usually  a  false  movement  in  coitus,  though 
a  wrench  or  a  blow  will  also  produce  it,  as,  for  instance,  when  the 
penis  is  caught  in  closing  a  bureau  drawer,  or  is  bruised  by  a  falhng- 
window-sash.  Demarquay  states  that  it  occurs  mainly  in  those  suf- 
fering from  a  partial  calcification  of  the  fibrous  sheath  of  the  penis. 
The  foolish  custom  of  "breaking"  a  chordee,  at  one  time  quite  fre- 
quent among  venereal  patients,  occasioned  a  number  of  cases  of  this 
injury. 

Symptoms. — The  symptoms  of  this  injury  are  sudden  severe  pain 
and  a  sense  of  something  liaving  given  way,  consequent  on  a  bending 
or  twisting  strain  of  the  erect  penis.  The  erection  subsides  at  once, 
and  there  is  rapid  and  immediate  swelling.  Deformity,  unless  masked 
by  the  swelling,  is  pronounced.  The  part  of  the  penis  anterior  to  the 
break  is  preternaturally  movable,  and  at  the  seat  of  injury  there  is  an 
angle  producing  a  flail-like  appearance. 

Prognosis. — The  prognosis  is  only  moderately  good.  The  subcu- 
taneous effusion  of  blood  may  possibly  cause  so  much  tension  that 
gangrene  will  be  threatened.  This,  however,  is  rare,  and  under 
proper  antiseptic  treatment  suppuration  will  not  occur,  except  when 
the  spongy  body  and  urethra  have  been  involved  in  the  injury  and 
there  is  extravasation  of  urine. 

The  prognosis  as  to  functional  restoration  must  always  be  some- 
what guarded.  In  some  cases  this  apparently  has  been  perfect.  In 
others  there  has  remained  an  indurated  mass  at  the  seat  of  injury, 
which  has  seriously  interfered  with  erections  and  has  resisted  all 
treatment. 

Treatment. — Rest  in  bed,  the  firm  bandaging  of  the  penis  in  the  erect 
position  against  the  abdomen,  the  application  of  evaporating  lotions,  and, 
if  needful,  drawing  the  water  by  catheter  (see  page  24)  usually  will  be 
followed  by  arrest  of  hemorrhage  and  gradual  absorption  of  clot. 

When  the  blood  effusion  forms  a  large  tumor,  and  particularly  when 
the  hemorrhage  continues,  threatening  by  tension  the  vitality  of  the 
part,  an  incision  must  be  made,  thus  allowing  ligature  of  the  bleeding 
vessels  and  accurate  suture  of  the  torn  fibrous  sheath.  Pressure  is 
applied  by  bandaging  the  penis  against  the  abdomen.  Erections  are 
prevented  by  keeping  the  bowel*  opened  and  by  giving  full  doses  of 
potassium  bromide  (gii  to  ^iv  daily). 


26  GEJSriTO-URINAKY   DISEASES   AND   SYPHILIS. 

Dislocation  of  the  Penis. — This  accident  is  produced  by  trau- 
matism exerted  upon  the  anterior  portion  of  the  flaccid  organ.  The 
penis  is  pinched  out  of  its  sheath  and  driven  into  tlie  scrotum,  the 
loin,  or  the  neighboring  regions,  much  as  a  grape  is  squeezed  out  of 
its  sldn.  The  mucous  layer  of  the  prepuce,  which  should  prevent* 
this  accident,  gives  way  either  at  the  preputial  orifice  or,  more  com- 
monly, along  the  line  of  the  coronary  sulcus.  The  urethra  is  usually 
ruptured  in  the  perineal  region. 

Symptoms. — The  symptoms  of  this  accident  are  not  so  marked  as 
would  be  supposed.  The  skin  sheath  of  the  penis  is  often  filled  with 
clotted  blood,  thus  simulating  the  presence  of  a  shrunken  organ. 
There  is  usually  free  hemorrhage  from  the  preputial  orifice.  Later 
there  is  extravasation  of  urine,  with  its  concomitant  symptoms. 
Careful  investigation  will  always  show  the  absence  of  the  erectile 
tissues  from  their  proper  position  and  their  presence  elsewhere. 

Treatment. — The  treatment  consists  in  immediate  replacement  of 
the  organ.  This  usually  requires  an  incision,  though  in  one  reported 
case  the  penis  was  hooked  forward  by  an  instrument  introduced  into 
the  preputial  orifice.  There  should  be  no  hesitation  in  making  the 
required  incision  so  free  that  the  proper  manipulations  for  reduction 
can  be  easily  carried  out.  After  this,  if  there  has  been  extravasation 
of  urine,  an  external  perineal  urethrotomy  should  be  performed. 

INFLAMMATORY   AFFECTIONS   OF  THE   PENIS. 

The  penis  and  its  envelopes  are  subject  to  the  inflammations  ob- 
served in  other  parts  of  the  body.  Aside  from  the  distinctly  venereal 
diseases,  eczema,  dermatitis  (notably  that  from  ivy  poisoning),  pruritus, 
urticaria,  erythema  intertrigo,  the  bites  of  insects,  parasitic  diseases, 
herpes,  erysipelas,  lymphangitis,  folliculitis,  abscess,  diffuse  cellular 
inflammation,  and  gangrene  are  to  be  noted. 

Eczema  very  commonly  affects  both  the  scrotum  and  the  penis, 
and  is  extremely  rebellious  to  treatment.  The  exciting  cause  is  often 
chafing  or  rubbing  of  the  parts,  though  a  constitutional  dyscrasia, 
such  as  gout  or  rheumatism,  commonly  predisposes  to  the  disease. 
It  usually  appears  on  the  prepuce  or  about  the  base  of  the  penis. 

The  treatment  is  the  same  as  for  the  disease  situated  in  other 
parts  of  the  body,  except  that,  as  the  skin  is  extremely  sensitive,  irri- 
tating applications  must  be  avoided. 

Herpes  of  the  entire  penis  is  rare ;  it  usually  attacks  the  foreskin 
and  glans.     (See  page  33.) 

Acute  inflammation  of  the  penis  may  be  localized  or  diffuse. 
It  may  involve  the  subcutaneous  ceflular  tissue  or  the  structure  of  the 


DISEASES   AND   INJURIES   OF    THE   PENIS.  27 

erectile  tissue.  Localized  inflammation  results  in  abscess.  This  is 
treated  in  accordance  with  general  principles,  whether  it  be  super- 
ficial or  placed  in  the  substance  of  the  organ, — i.e.,  it  is  opened  and 
drained. 

The  diffuse  inflammation  may  appear  in  the  form  of  erysipelas  of 
the  subcutaneous  tissues,  or  may  attack  the  substance  of  the  erectile 
tissue,  constituting  the  affection  called  penitis.  Elevation  and  the 
application  of  evaporating  lotions  are  indicated,  followed  by  incision 
and  drainage  should  there  be  pus-formation. 

Gangrene  occasionally  results  from  deep-seated  acute  inflamma- 
tion, which  may  be  due  to  local  causes,  such  as  phimosis  or  paraphi- 
mosis, traumatism,  or  urinary  extravasation,  or  may  develop  as  a 
result  of  thrombosis  after  acute  fever,  such  as  typhoid,  or  may  be 
incident  to  diabetes.  The  trophoneurotic  gangrene  secondary  to 
cord  lesions  is  guarded  against  by  dry  cleanliness  and  the  avoidance 
of  pressure. 

Treatment. — The  treatment  of  gangrene  of  the  penis  is  that  ap- 
plicable to  this  condition  in  other  parts  of  the  body.  In  case  the 
gangrene  is  rapidly  spreading,  removal  of  the  dead  tissue  by  scissors 
and  curette,  supplemented  by  thorough  application  of  the  actual 
cautery,  is  indicated.  Compresses  soaked  in  hot  bichloride  solution 
(1  to  10,000)  and  changed  every  half-hour  are  applied  till  healthy 
granulations  form,  when  boric  ointment,  or  a  dry  dusting  powder,  such 
as  iodoform,  or  acetanilid,  may  be  substituted. 

When  gangrene  is-  less  fulminant  in  type,  hot  compresses,  changed 
every  three  minutes  (bichloride  solution  1  to  10,000,  at  a  tempera- 
ture of  110°  F.),  may  be  applied  for  twenty-four  hours,  supple- 
mented by  thorough  spraying  of  the  involved  parts  with  peroxide 
solution  every  two  hours.  When  the  gangrene  is  distinctly  slow  in 
type  and  resists  ordinary  treatment,  a  long-continued  general  bath 
or  hip  bath  is  indicated.  This  should  be  kept  comfortably  hot  and 
should  be  mildly  antiseptic  (gss  bichloride,  or  §xii  boric  acid,  to  the 
bath).  The  genitalia  should  be  kept  submerged  day  and  night  for 
days,  and  even,  in  exceptional  cases,  for  weeks.  Many  of  these 
cases  of  indolent  gangrene  are  late  manifestations  of  tertiary  syphilis 
in  persons  afflicted  with  visceral  disease.  This  is  shown  by  the 
fact  that  a  vigorous  course  of  inunctions  and  potassium  iodide  will 
at  times  cause  the  rapid  healing  of  necrotic  lesions  which  have  for 
weeks  or  months  proved  absolutely  rebellious  to  every  other  form  of 
treatment. 

The  systemic  treatment  is  extremely  important  in  all  cases  of  gan- 
grene.    This  must  be  tonic  and  stimulating.     Easily  digestible  food  in 


28 


GENITO-ITPvINAKY   DISEASES    A:ND   SYPHILIS. 


Fig.  15. 


as  full  quantity  as  can  be  given,  tonics,  particularly  iron,  strychnine, 
and  small  doses  of  bichloride  (grain  one-sixtieth  thrice  daily),  and 
stimulants  are  indicated.  The  bowels  should  be  moved  regularly. 
Diabetic  gangrene  should  receive  appropriate  constitutional  treatment. 
Chronic  inflammation  of  the  erectile  tissue  and  its  fibrous 
envelope,  particularly  of  the  corpora  cavernosa,  results  in  slow,  often 
painless,  areas  of  induration,  which  may  be  fibrous,  calcareous,  or 
even  bony  (Fig.  15),  and  which  require  attention  only  because  they 
prevent  complete  erection.  The  cause  of  these  indurations  is  un- 
known. They  are  observed  in  middle-aged  men,  and  are  often 
associated  with  the  rheumatic  and  gouty  diath- 
eses. They  have  been  regarded  as  late  lesions  of 
syphilis.  With  this  disease  they  probably  have 
no  relation,  though  it  must  be  remembered  that 
gummata  may  appear  in  the  corpora  cavernosa. 

Symptoms. — The  symptoms  of  this  affection 
are  sufficiently  characteristic.  Palpation  demon- 
strates one  or  more  circumscribed,  hardened, 
possibly  tender  areas,  varying  from  the  size  of  a 
split  pea  to  that  of  the  thumb-nail.  The  erect 
penis  is  bent  at  the  seat  of  hardening,  and  often 
erection  is  incomplete  in  the  portion  of  the  in- 
volved cavernous  body  lying  to  the  distal  side  of 
the  lesion. 

Treatment. — The  treatment  of  this  affection  is 
v^^ithout  avail.  In  the  early  stages,  when  slight 
constant  pain  and  beginning  hardness  indicate  the 
nature  of  the  case,  pressure  by  means  of  a  thin 
rubber  bandage,  inunctions  of  mercuric  ointment, 
and  the  internal  administration  of  potassium 
iodide  and  wine  of  colchicum  root,  continued  for 
many  months,  may  prevent  permanent  crippling. 
When  the  lesions  are  fully  formed  the  same  treat- 
ment may  be  tried,  but  with  slight  prospect  of  success.  When  a  cal- 
careous or  a  bony  plate  materially  interferes  with  functional  activity 
and  is  placed  superficially,  there  can  be  no  objection  to  removing  it  by 
a  cutting  operation,  but  the  operator  should  hold  out  no  definite  hope 
of  restoration  of  function. 

Inflammatory  lymphangitis  is  secondary  to  peripheral  inflam- 
mation, sometimes  non-specific,  but  usually  of  venereal  origin. 

Symptoms. — The  inflammation  usually  affects  the  lymphatics  of  the 
dorsum  of  the  penis.     Beneath  the  skin  can  be  felt  one  or  more  cords,. 


Osseous  growth  of  the 
penis.   (Demarquay.) 


DISEASES   AND    INJUEIES   OF   THE    PENIS.  29 

often  starting  about  the  region  of  the  fraenum  and  passing  upward  and 
backward  behind  the  corona  to  the  dorsum  of  the  penis,  along  which 
a  distinct  cord  can  be  felt  extending  as  far  back  as  the  symphysis 
pubis.  This  cord  is  tender,  hard,  not  very  sharply  circumscribed, 
and  over  its  course  the  skin  is  reddened  and  sometimes  adherent. 
This  line  of  induration  may  attain  the  size  of  a  lead-pencil,  and  may 
even  be  much  larger  than  this.  It  is  attended  with  a  great  deal  of 
pain,  which  is  especially  severe  during  erection.  Exceptionally  an 
indurated  knob  forms  sometimes  just  behind  the  corona  in  the  loose 
subcutaneous  connective  tissue,  sometimes  in  the  course  of  the  dorsal 
lymphatics ;  this  slowly  enlarges,  giving  comparatively  little  pain, 
softens,  and  on  being  opened  discharges  pus.  From  this  a  persistent 
fistula  may  result  which  can  be  cured  only  by  extirpation. 

Gonorrhoeal  lymphangitis  may  be  distinguished  from  that  which 
characterizes  hard  chancre  by  the  fact  that  its  outlines  are  not  sharply 
circumscribed,  the  inflammation  commonly  extending  to  the  surround- 
ing cellular  tissue,  and  by  its  being  tender  and  painful,  and  involving 
the  skin  and  producing  the  redness  and  cedema  characteristic  of  acute 
inflammation. 

It  would  be  extremely  difficult  to  distinguish  lymphangitis  from 
dorsal  phlebitis.  This  latter  complication  of  inflammatory  affections 
of  the  urethra,  glans  and  foreskin,  if  it  ever  does  occur,  is  certainly 
exceedingly  rare.  It  would  be  necessarily  attended  by  much  more 
swelling  of  the  penis,  and  would  not  be  accompanied  by  that  enlarge- 
ment of  the  lymphatic  glands  of  the  groin  which  is  rarely  absent  when 
lymphangitis  of  the  penis  is  observed.  Moreover,  the  vein  passes 
backward  in  the  middle  line,  and  is  not  deflected  towards  the  groins  as 
is  the  case  with  the  lymphatic  vessels,  and  is  placed  more  deeply  so 
ihat  it  cannot  be  lifted  up  with  the  skin. 

Treatment. — Free  drainage  of  pus  from  the  anterior  urethra,  ap- 
propriate treatment  directed  towards  lessening  the  severity  of  the 
urethritis,  and  careful  cleansing  of  the  preputial  sac  are  matters  which 
should  receive  close  attention.  Following  these,  rest  should  be  en- 
joined, the  bowels  should  be  opened,  and  continuous  applications 
should  be  made  of  cloths  kept  wet  with  alcohol  and  lead  water  equal 
parts.  Hot  baths,  local  or  general,  are  also  serviceable,  and  when  the 
erections  become  troublesome  potassium  bromide  should  be  given  in 
sufficient  doses  to  control  them.  This  drug  faihng,  hypodermics  of 
morphine  may  be  given  at  night  to  procure  rest.  When  pus  forms  it 
should  be  evacuated  by  incision,  the  remaining  cavity  being  curetted 
and  packed  from  the  bottom. 

In  a  very  rare  form  of  lymphangitis  the  lymphatic  vessels  of  the 


30  GEXITO-UIIIXARY    DISEASES   AND    SYPHILIS. 

prepuce  are  dilated  without  marked  inflammatory  phenomena.  The 
symptoms  of  this  affection  usually  appear  after  coitus  or  other  cause 
of  acute  congestion.  On  retraction  of  the  prepuce  the  congested, 
semi-transparent  lymph-vessels  are  easily  detected,  passing  upward 
and  backward  from  the  freenum  towards  the  dorsum  of  the  penis. 
The  swelling  subsides  in  a  few  days,  but  recurs  after  each  attempt 
at  coitus,  until  finally  it  becomes  permanent.  When  the  swollen 
vessels  are  unduly  prominent,  mechanical  disturbance  is  follow'ed  by 
marked  symptoms  of  local  inflammation. 

The  treatment  in  the  early  stages  consists  in  prolonged  hot  local 
baths  and  the  use  of  astringents.  Fluid  extract  of  hamamelis,  one  part 
to  four  parts  of  water ;  ammoniated  mercurial  ointment,  ten  grains 
to  the  ounce  of  carbolated  cosmoline ;  ointment  of  belladonna  and 
mercury,  one  part  to  four  parts  of  lanolin,  well  rubbed  in ;  or  com- 
presses kept  wet  in  lead  water  and  laudanum,  Avill  often  effect  a 
cure. 

When  the  dilatation  becomes  permanent  surgical  interference  is 
necessary.  A  seton  passed  through  the  enlarged  vessel  or  excision 
of  a  portion  of  its  length  wall  be  followed  by  a  temporarj'-  increase  of 
swelling,  but  ultimately  by  obliteration  and  cure. 

Phlebitis  occurs  secondarily  to  other  lesions  of  the  penis  or 
urethra.  A  dense  indurated  cord  is  felt  along  the  course  of  the  vein, 
and  there  is  great  swelling.  Suppuration  is  rare,  and  treatment  by 
evaporating  lotions  and  rest  and  catharsis  is  usually  efficient. 

VAmcosE  VEINS  of  the  penis  are  frequently  observed,  either  as  a 
local  expression  of  general  venous  dilatation  or  independently  of 
other  lesions  of  a  similar  kind  and  as  a  sequel  of  inflammation. 
Usually  they  occasion  no  inconvenience.  When  they  are  so  large  as  to 
interfere  with  coitus,  cure  may  be  effected  by  ligation  or  by  excision. 

The  inflammatory  affections  which  most  frequently  involve  the 
glans  and  prepuce  are  balanitis,  balanoposthitis,  and  herpes  progeni- 
talis. 

Balanitis  and  Balanoposthitis. — Balanitis  is  an  inflammation 
of  the  surface  of  the  gians  penis.  Balanoposthitis  is  an  inflammation 
of  both  this  surface,  and  the  mucous  layer  of  the  foreskin.  Posthitis 
is,  of  course,  an  inflammation  of  the  mucous  layer  of  the  foreskin 
alone.     They  may  be  considered  together. 

Causes. — The  principal  predisposing  cause  of  these  inflammations 
is  a  redundant  or  phimotic  foreskin.  This  keeps  the  apposed  mucous 
surfaces  macerated  and  irritated,  favors  retention  and  consequent  de- 
composition of  smegma  and  urine,  and  offers  conditions  most  pro- 
pitious to  a  successful  inoculation  w'hen  specific  virus  is  introduced 


Fig.  16. 


Balanitiii. 


Fig.  1 


Herpes  of  the  glans. 


DISEASES   AND   INJURIES   OF   THE    PENIS.  31 

within  the  preputial  sac.  The  gouty  or  rheumatic  diathesis  and  dia- 
betes also  predispose  to  this  form  of  inflammation. 

The  exciting  causes  are  either  mechanical,  as  from  friction  or 
abrasion,  or  chemical,  as  from  contact  with  irritating  discharges,  like 
those  from  chancre,  chancroid,  or  gonorrhoea,  or  from  non-specific 
lesions,  as  endometritis.  The  pus  cocci  and  the  colon  bacilli  are  the 
usual  causative  factors. 

Symptoms. — The  symptoms  of  balanitis  in  its  mildest  form,  the 
form  from  which  most  men  who  are  not  careful  as  to  local  cleansing 
suffer  at  times,  are  a  sense  of  heat  and  itching  about  the  end  of  the 
penis,  some  redness  and  swelling  near  the  preputial  orifice,  a  dis- 
charge which  crusts  and  is  extremely  offensive,  and  on  stripping  back 
the  foreskin  a  hypersemic  infiltrated  mucous  membrane  exhibiting  on 
its  surface  a  thick,  creamy  deposit,  and  at  times  patches  of  super- 
ficial excoriation.  (Fig.  16.)  In  the  coronary  sulcus  is  found  an 
abnormal  quantity  of  semi-liquid,  offensive  smegma. 

In  severe  cases  the  excoriations  are  extensive  and  well  marked, 
inflammatory  phenomena  are  more  pronounced,  and  the  whole 
prepuce  becomes  greatly  swollen,  and  in  consequence  phimotic 
(inflammatory  phimosis).  The  discharge  is  profuse.  This  form  is 
often  secondary  to  gonorrhoea,  chancroids,  syphilitic  lesions,  or  gen- 
eral troubles,  such  as  diabetes.  It  is,  however,  not  due  to  the  direct 
action  of  specific  germs  of  the  venereal  disease,  the  gonococcus,  for 
example,  but  to  the  irritation  incident  to  the  contact  with  decomposing 
discharges  and  to  infection  with  the  ordinary  staphylococci.  (See 
page  184.) 

In  certain  cases  the  erosions  and  superficial  ulcerations  start  from 
the  corona,  exhibit  circinate  borders,  and  progressively  involve  the 
entire  mucous  membrane  of  the  glans  and  foreskin,  lasting  fcr  several 
weeks,  and,  so  far  as  extension  is  concerned,  resisting  all  treatment. 

As  a  consequence  of  balanoposthitis  there  may  develop :  (1) 
lymphadenitis  ;  (2)  condylomata  ;  (3)  hypertrophy  ;  (4)  gangrene. 

Lymphadenitis,  at  least  the  suppurative  form  of  the  affection,  is 
rare. 

Condylomata  frequently  develop  during  or  after  balanoposthitis. 

Hypertrophy  of  the  foreskin,  in  the  sense  of  a  greatly  elongated, 
thickened,  rigid  prepuce,  interfering  with  physiological  activity,  may 
result  in  consequence  of  organization  of  the  inflammatory  infiltration 
consequent  on  repeated  attacks  of  acute  or  subacute  inflammation. 
It  is  noticed  in  middle-aged  men,  especially  diabetics,  and  is  usually 
accompanied  by  chronic  inflammatory  lesions  of  the  glans  or  pre- 
puce.    It  is  sometimes  followed  by  epithelioma. 


32  G-ENITO-URINAKY   DISEASES   AND   SYPHILIS. 

When  the  inflammation  is  hyperacute,  inflammatory  swelling  may 
be  followed  by  gangrene.  This  is  scarcely  possible  except  in  phi- 
motic  cases.  There  is  little  danger  to  life  in  this  process,  which  is 
self-correcting.  There  may  be,  however,  ultimate  cicatricial  de- 
formity. 

Diagnosis. — The  superficial,  irregular  or  circinate  erosions,  to- 
gether with  the  surrounding  surface  hyperaemia  and  the  character- 
istic discharge,  render  diagnosis  fairly  easy  when  the  foreskin  can  be 
retracted. 

Herpes  will  at  first  exhibit  vesicles,  and,  when  these  vesicles  have 
ruptured,  circinate  lesions.  The  distinction  between  these  and  the 
erosions  of  balanoposthitis  is,  however,  not  always  possible,  nor  is  it 
important. 

Chancroidal  balanoposthitis  develops  insidiously,  is  characterized 
by  an  inflammatory  infiltration  or  thickening  or  hardening  of  the 
glans  and  foreskin  rather  than  by  an  acute  oedema,  exhibits  more  dis- 
tinctly circumscribed  erosions,  which  are  shortly  converted  into  true 
ulcers,  and  is  soon  followed  by  characteristic  inguinal  adenopathy. 

Syphilitic  balanoposthitis,  occurring  as  a  secondary  lesion,  would 
be  diagnosed  by  the  history  of  the  case,  the  appearance  of  character- 
istic lesions  on  other  surfaces  of  the  body,  and  the  development  of 
moist  papules  primarily,  after  which  neglect  of  treatment  might  occa- 
sion a  general  inflammation  of  the  preputial  sac. 

Only  in  cases  of  purulent  discharge  complicated  by  tight  phimosis 
Avould  there  be  difficulty  in  deciding  between  balanoposthitis,  chancre, 
€hancroid,  and  gonorrhoea.  Gonococci  would  prove  that  gonorrhoea 
was  present,  auto-inoculation  of  discharge  would  show  the  presence 
of  chancroid  (although  this  is  not  to  be  recommended  as  routine  prac- 
tice), and  a  distinctly  indurated  area  felt  beneath  the  prepuce  would 
suggest  chancre.  If,  however,  the  prepuce  were  reddened,  swollen, 
and  painful,  whatever  the  primary  lesion,  these  symptons  would 
almost  certainly  denote  the  development  of  balanoposthitis,  and  would 
call  for  the  treatment  appropriate  to  this  form  of  inflammation. 

Treatment. — -The  basis  of  all  treatment  is  cleanliness.  If  the  pre- 
puce can  be  retracted,  the  inflamed  mucous  surfaces  are  washed  with 
a  mild  antiseptic  solution,  dilute  subacetate  of  lead  lotion,  or  bichloride 
solution  1  to  4000,  dried  by  means  of  absorbent  cotton,  and  the  ero- 
sions brushed  with  a  ten  per  cent,  silver  nitrate  solution ;  the  parts 
are  then  dusted  with  a  powder  made  of  equal  parts  of  bismuth  sub- 
nitrate  and  calomel,  a  very  thin  layer  of  absorbent  cotton  is  placed 
over  the  glans,  and  the  foreskin  is  drawn  forward.  This  dressing 
should  be  changed  several  times  daily. 


DISEASES   AND    INJUEIES   OF    THE    PKNIS.  33 

When  the  discharge  is  profuse,  very  finely  powdered  alum  or 
tannin  may  be  used  in  place  of  the  calomel  and  bismuth.  Lumpy  or 
gritty  dusting  powders  do  more  harm  than  good. 

When  the  inflammation  is  unusually  acute  in  type  and  erosions 
are  extensive,  a  wet  dressing  is  indicated.  Under  such  circum- 
stances, after  washing,  the  dusting  powder  and  silver  nitrate  are 
omitted,  the  thin  layer  of  dry  cotton  being  placed  directly  on  the 
glans  and  then  wet  with  the  required  solution,  preferably  dilute  lead 
water,  or  fluid  extract  of  hydrastis  canadensis  1  part,  rose  water  9 
parts.  In  phimotic  cases  the  preputial  sac  should  be  washed  out 
every  two  hours,  first  with  warm  water  and  soap,  then  with  clear 
water,  and  then  with  mild  antiseptic  solutions,  such  as  sublimate 
1  to  4000,  or  carbolic  acid  1  to  500,  or,  better  still,  a  solution  con- 
taining both  these  antiseptics  in  the  proportion  just  given.  This 
Avashing  is  best  accomplished  by  means  of  a  hard  rubber  syringe  pro- 
vided with  a  conical  nozzle,  though  when  the  preputial  orifice  is 
sufficiently  large  a  flat  nozzle  will  occasion  less  irritation.  The  whole 
preputial  sac  should  be  ballooned  out  with  the  solution,  unless  great 
pain  is  caused  by  this  distention.  Following  the  antiseptic  injection 
the  hydrastis  solution  1  to  10  should  be  used.  When  suppuration 
is  very  profuse,  peroxide  of  hydrogen  may  precede  the  antiseptic 
injection. 

General  swelling  of  the  prepuce  is  combated  by  keeping  the  parts 
wrapped  in  hnt  wet  in  dilute  alcohol  and  lead  water  ec|ual  parts. 

When  gangrene  threatens,  an  attempt  to  abort  may  be  made  by 
continued  hot  local  baths, — i.e.,  soaking  the  penis  in  dilute  antiseptic 
solution  as  hot  as  can  be  borne  for  two  hours  at  a  time,  two  or  three 
times  a  day.  If  this  does  not  promptly  relieve  tension,  the  prepuce 
should  be  split  along  its  dorsum,  exposing  the  inflammatory  lesions 
and  allowing  them  to  be  treated  directly. 

Chancroidal  balanoposthitis,  or  that  comphcating  diabetes,  is  alone 
liable  to  occasion  such  marked  swelUng  as  to  require  splitting  of  the 
foreskin.  Under  these  circumstances,  the  immediate  completion  of 
the  operation  by  circumcision  involves  more  risk  than  usual,  but  may 
be  attempted  after  the  patient  has  been  fully  warned  as  to  the  danger 
of  infection  of  the  wound.  Good  results  may  be  obtained  by  follow- 
ing the  procedure  described  under  Chancroid.  (See  page  53.)  In 
diabetic  cases,  in  this  region  as  elsewhere,  rigid  antisepsis  is  of 
especial  importance. 

Herpes  Progenitalis. — This  affection  is  characterized  by  the 
rather  sudden  appearance  of  vesicles  clustering  upon  erythematous 
bases   situated  on  the   mucous  or  skin  surfaces   of  the  penis,  and 

3 


34  GENITO-UEINAET   DISEASES   AND   SYPHILIS. 

attended  with  itching  and  burning.  (Fig.  17.)  ComnioJily  they 
appear  in  or  about  the  coronary  sulcus,  involving  both  the  glans  and 
the  foreskin.  When  thus  placed  the  covering  of  these  vesicles  is 
quickly  macerated,  leaving  rounded  or  irregular  erosions  which  may 
become  confluent  but  still  exhibit  a  polycyclic  outline.  A  mild 
balanoposthitis  usually  complicates  herpes,  and  the  affection  some- 
times causes  suppurating  buboes.     Warts  frec{uently  develop. 

When  these  lesions  are  neglected  the  abrasions  may  be  converted 
into  punched-out  ulcers  (ulcerating  herpes). 

Sometimes  the  lesions  are  accompanied  by  intense  pain,  much 
like  that  of  herpes  zoster;  the  affection  is  then  termed  neuralgic 
herpes.  The  pain  may  precede  the  development  of  the  vesicles, 
which  may  be  so  few  and  discrete  as  to  attract  httle  attention.  Ex- 
ceptionally there  is  marked  sexual  erethism,  causing  prolonged  erec- 
tions and  nocturnal  pollutions.  The  burning  shooting  pain  is  generally 
confined  to  the  penis  ;  occasionally  it  is  reflected  to  the  perineum  and 
the  groins,  and  even  down  the  thighs.  This  neuralgic  herpes  is  some- 
times accompanied  by  urethral  discharge  simulating  gonorrhcea,  but 
differing  from  it  in  the  absence  of  gonococci.  This  discharge  is  not 
favorably  influenced  by  local  or  general  treatment.  Herpes  having 
once  appeared  is  prone  to  develop  again  ;  at  times  the  recurrence  is 
observed  hard  upon  the  first  attack,  new  crops  of  vesicles  forming  as 
fast  as  earlier  lesions  are  healed.  More  frequently  there  is  a  dis- 
tmct  interval  between  attacks.  When  it  has  this  tendency  to  relapse 
it  is  called  recurrent,  and  is  often  neuralgic  in  type.  Herpes  appearing 
upon  the  skin  surface  of  the  prepuce  does  not  differ  from  the  eruption 
as  observed  on  other  surfaces  of  the  body.  The  eruption,  wherever  it 
is  situated,  may  be  discrete,  even  to  the  extent  of  the  formation  of  but 
one  or  two  vesicles,  or  confluent,  forming  in  this  case  usually  small 
patches,  sometimes  completely  covering  large  surfaces  and  causing  in- 
tensely painful  inflammatory  erosions.  The  pain  is  so  severe  that  the 
system  suffers,  and  the  patients,  generally  women,  are  confined  to 
bed. 

Etiology. — The  causes  of  herpes  are  practically  the  same  as  those 
of  balanoposthitis.  The  eruption  is  predisposed  to  by  rheumatism, 
gout,  and  a  neurotic  tendency  ;  also  locally  by  any  causes  tending  to 
excite  inflammation,  such  as  phimosis  and  urethral  or  preputial  dis- 
charges. The  mechanical  irritation  of  immoderate  coitus,  together 
with  the  effect  of  prolonged  contact  with  any  irritating  uterine  or 
vaginal  discharge,  may  be  an  exciting  cause. 

The  diagnosis  of  herpes  is  founded  upon  the  rather  sudden  appear- 
ance of  vesicles  in  clusters,  either  without  obvious  cause  or  following 


DISEASES   AND    INJURIES    OF   THE    PENIS.  35 

closely  upon  mechanical  or  chemical  irritation.  When  the  lesions  are 
observed  in  their  vesicular  stage  they  cannot  well  be  confounded  with 
any  other  affection.  Thus,  when  they  appear  on  the  skin  of  the  penis 
or  scrotum  there  can  be  no  doubt  as  to  their  nature.  When  they  are 
placed  on  the  mucous  surfaces  of  the  glans  and  foreskin,  however, — 
and  this  is  their  usual  situation, — they  are  rarely  observed  before 
the  coverings  of  the  vesicles  have  been  macerated  and  the  lesions  are 
erosive  or  ulcerative  in  type.  Even  then  they  are  usually  super- 
ficial, multiple,  circular,  or,  when  confluent,  at  least  circinate  in  type, 
non-indurated,  except  when  placed  at  or  within  the  urethral  orifice, 
rapid  in  development,  non-progressive,  with  moist,  red  surface,  when 
squeezed  give  a  slight  serous  discharge,  and  if  kept  clean  rapidly  heal, 
though  new  lesions  may  occur  on  previously  healthy  surfaces. 

The  differential  diagnosis  must  be  made  from  chancre,  chancroid, 
balanoposthitis,  and  mucous  patches.  The  points  of  difference  be- 
tween herpes,  chancre,  and  chancroid  are  tabulated  on  page  834 ; 
though  it  is  of  sufficient  importance  to  be  repeated  here  that  herpes 
sometimes  (about  once  in  ten  cases)  causes  painless  polyganglionic 
bilateral  inguinal  adenitis,  exactly  like  that  following  chancre. 

The  lesions  of  balanoposthitis  are  usually  more  diffuse  and  rather 
irregular  or  serrated  than  polycyclic  in  outhne.  Moreover,  they  are 
not  preceded  by  vesicles.  The  differential  diagnosis  cannot  always 
be  made,  since  herpes  is  generally  accompanied  by  more  or  less 
balanoposthitis.  Mucous  patches  are  accompanied  by  other  mani- 
festations of  syphilis,  are  slower  in  development  than  herpes,  do  not 
begin  as  vesicles,  and  present  a  grayish  necrotic  pseudo-membrane  in 
place  of  the  red,  moist,  shining  surface  of  the  herpetic  lesion. 

Treatment. — Cleanliness  is  the  key-note  of  successful  treatment. 
Antiseptic  washings,  careful  drying,  painting  with  silver  nitrate,  dusting 
with  zinc  oxide  or  bismuth,  the  interposition  of  a  thin  layer  of  cotton 
between  the  two  mucous  surfaces,  and,  if  necessary,  the  remainder 
of  the  treatment  described  as  appropriate  to  balanoposthitis,  ordi- 
narily bring  about  cure  in  a  few  days.  When  the  inflammation  is 
more  than  usually  acute,  a  wet  dressing  should  be  substituted  for  the 
dusting  powder.  In  the  ulcerating  form  the  system  is  usually  at  fault ; 
here  treatment  appropriate  to  the  general  condition  present  should 
supplement  local  treatment,  the  gouty  or  tubercular  diathesis  receiving 
proper  medication  and  diet. 

Neuralgic  herpes  is  often  benefited  by  painting  with  silver  nitrate 
solution  ten  grains  to  the  ounce,  or  solution  of  chloral  one  drachm  to 
the  ounce,  or  carbolic  acid  lotion  1  to  60 ;  the  erosions  should  then 
be  dressed  as  already  described.     This  form  of  herpes  is,  however,  not 


36  GENITO-UEIlSrAKY   DISEASES   AND    SYPHILIS. 

readily  influenced  by  treatment.  Local  applications  of  cocaine  will 
sometimes  relieve  the  pain.  This  may  be  sprayed  on,  a  four  per  cent, 
solution  being  used,  or  the  following  ointment  may  be  appHed  : 

B   Cocainse  hydrochlor.,  gr.  xii ; 

Menthol,  gr.  i ; 

Lanolin,  giv. 
M.     S.— Use  locally. 

When  the  pain  is  harassing  and  unrelieved  by  local  treatment,  the 
galvanic  current  may  be  tried ;  this  failing,  the  suffering  should  be 
relieved  by  an  anodyne,  since  it  will  cease  spontaneously  in  from  four 
to  twelve  days. 

Recurrent  herpes  is  most  frequently  observe'd  in  connection  with 
a  redundant  or  phimotic  prepuce  or  stricture.  The  cure  of  these 
conditions  will  often  bring  permanent  relief.  When  there  seems  to 
be  no  local  predisposing  factor,  the  surfaces  most  often  affected  should 
be  frequently  bathed  in  aqueous  solutions  of  hydrastis  extract  1  to  5, 
or  hot  saturated  solution  of  alum,  and  after  exposure  to  any  form 
of  irritation  should  be  thoroughly  cleansed  with  mild  antiseptic  lotions, 
washed  with  the  astringent,  carefully  dried,  and  dusted  with  stearate 
of  zinc  or  bismuth,  or  carbolized  talc.  A  general  tonic  and  support- 
ing dietetic  and  medicinal  treatment  should  be  prescribed  at  the  same 
time,  minute  doses  of  arsenic  and  bichloride  of  mercury  (grain  one- 
sixtieth  of  each  t.  i.  d.)  and  the  less  irritating  iron  preparations  being 
particularly  indicated. 

CHANCROID. 

The  chancroid  is  a  contagious  venereal  ulcer.  It  has  no  distinct 
period  of  incubation,  is  inflammatory  and  destructive  in  type,  and  is 
frequently  accompanied  by  suppurating  buboes.  It  is  a  local  and  not 
a  constitutional  disease.  It  has  been  variously  named  soft  chancre, 
simple  chancre,  and  non-infecting  sore. 

Cause. — Chancroid  is  due  to  the  local  action  of  micro-organisms. 
The  pus  is  highly  contagious,  even  when  diluted  ;  bactericides  of 
moderate  strength  destroy  its  virulence. 

It  is  often  accepted  that  chancroid  is  a  simjjle  ulcer  caused  by  the 
inoculation  of  the  well-known  pyogenic  microbes  upon  an  abraded 
surface.  It  is  held  that  this  ulcer  runs  a  somewhat  pecuhar  course  on 
account  of  the  anatomical  and  physiological  peculiarities  of  the  tissues 
upon  which  it  is  usually  situated.  This  behef  is  founded  on  the  facts 
that  the  ordinary  pyogenic  microbes  are  always  present  in  chancroidal 
discharge,  and  that  these  sores  are  most  frequently  encountered  on 


DISEASES   AND   INJURIES    OF   THE    PENIS.  37 

the  persons  of  those  who  are  most  exposed  to  infection  by  pyogenic 
microbes, — i.e.,  those  who  are  micleanly.  Moreover,  inoculation  with 
the  pus  of  acne  or  of  furuncle  may  produce  sores  presenting  the 
characteristics  of  chancroids. 

As  opposed  to  these  arguments  and  in  favor  of  the  dependence  of 
chancroid  upon  a  specific  virus,  the  following  points  are  worthy  of 
consideration.  In  addition  to  the  pyogenic  micro-organisms  found 
in  every  open  wound,  competent  observers  have  described  bacteria 
always  associated  with  chancroidal  lesions  and  appearing  as  pure 
cultures  when  repeated  auto-inoculations  are  practised  under  anti- 
septic precautions.  Chancroid  nearly  always  arises  from  contact 
with  the  discharge  from  chancroid,  and  not  as  a  result  of  the  irri- 
tating action  of  retained  or  decomposing  discharges  from  other  sources, 
The  chancroid  nearly  always  runs  a  typical  course,  even  in  healthy 
persons,  and  involves  the  anatomically  associated  lymphatic  glands  in 
degenerative  processes  with  far  greater  frequency  than  is  observed  in 
simple  infections  with  pyogenic  microbes.  Auto-inoculation  of  the 
discharge  of  the  fresh  chancroid  is  nearly  always  successful,  and  can 
be  repeated  almost  indefinitely.  The  inoculation  ulcers  after  a  second 
generation  show  no  pyogenic  micro-organisms,  but  only  those  which 
are  held  to  be  specific  to  the  lesion.  Auto-inoculation  with  pus  from 
an  ordinary  ulcer  usually  fails,  or,  if  successful,  it  produces  a  super- 
ficial lesion.  A  rapidly  extending  chancroid  if  thoroughly  cauterized 
is  at  once  converted  into  a  simple  ulcer,  and,  though  pyogenic  micro- 
organisms abound  in  the  discharge  of  the  latter,  the  lesion  runs  a 
benign  and  self-limited  course,  essentially  different  from  that  charac- 
teristic of  chancroid. 

Ducrey,  Welander,  and  Krefting  describe  as  the  specific  micro- 
organism of  chancroid  a  short,  thick  bacillus,  with  rounded  ends, 
much  like  a  dumb-bell,  about  one  and  a  half  micromillimetres  in 
length.  The  micro-organism  is  found  in  the  protoplasm  and  between 
the  cells,  often  in  chains  and  groups.     The  staining  solution  is  as 

follows : 

Five  per  cent,  boric  solution,  5ss ; 

Saturated  aqueous  solution  of  methyl-blue,  gv ; 

Distilled  water,  .^vi. 

Cover-glass  preparations  made  in  the  customary  way  are  allowed 
to  float  in  this  dye  for  half  an  hour.  They  are  then  washed  in  dis- 
tilled water,  dried,  and  examined.  The  discharge  from  the  chancroid 
may  contain  these  micro-organisms,  but  compared  with  the  number 
of  other  bacteria  they  are  extremely  few.  In  the  first  inoculation 
pustule  these  micro-organisms  are  more  numerous,  other  bacteria  be- 


38  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

coming  less  in  number.  In  the  pustules  of  the  third  generation  these 
bacteria  appear  as  pure  cultures.  In  no  instance  could  an  inoculation 
chancroid  be  produced  Avithout  finding  in  the  discharge  the  bacillus 
just  described. 

Though  the  specific  bacteria  of  chancroid  are  not  always  readily 
identified,  both  the  clinical  and  bacteriological  evidence  as  to  their  ex- 
istence is  convincing.  Thus  a  prompt  diagnosis  may  be  made  as  to 
the  nature  of  a  given  sore  and  an  appropriate  treatment  early  insti- 
tuted, since  remedies  efficient  against  an  ordinary  pyogenic  infection 
may  be  useless  in  chancroidal  infection. 

The  clinical  history  of  chancroid,  however,  marks  it  as  a  distinct 
and  separate  lesion. 

Fournier  states  that  where  a  chancroid  is  found  there  has  been 
deposited  chancroidal  virus,  and  many  other  observers  believe  that 
chancroid  is  invariably  due  to  inoculation  of  pus  derived  from  a 
similar  ulcer. 

The  InoGulahUity  of  Chancroid. — The  chancroid  is  capable  of 
almost  indefinite  reinoculation,  the  different  parts  of  the  body  showing 
varying  susceptibility  to  the  action  of  the  virus.  When  inoculations 
are  made  upon  the  thigh,  large,  sloughing  ulcers  not  infrequently 
result.  The  lesions  are  more  manageable  when  the  belly  is  inocu- 
lated ;  while  if  the  face,  chest,  or  arms  are  selected  they  are  still  less 
serious.  After  a  certain  time  the  skin  of  the  region  in  which  many 
inoculations  have  been  made  acquires  immunity  against  the  develop- 
ment of  further  sores.  This  immunity  is,  however,  only  temporary. 
Successive  inoculations  have  a  tendency  to  become  milder,  and  recent 
experiments  conducted  under  antiseptic  precautions  appear  to  show- 
that  the  original  pus  of  each  chancroid  can  be  auto-inoculated  only  a 
limited  number  of  times. 

In  the  early  stage  of  the  original  sore,  auto-inoculation  almost  in- 
variably succeeds,  producing  a  characteristic  chancroidal  lesion.  As 
the  original  sore  grows  older  the  virulence  of  the  pus  diminishes,  until 
finally  it  disappears  entirely,  inoculation  then  producing  simply  the 
slight  superficial  lesion  characteristic  of  the  irritation  of  ordinary  pus. 

According  to  Finger  and  others,  acute  diseases  attended  with  high 
fever,  such  as  pneumonia,  pleurisy,  and  the  exanthemata,  during  their 
course  render  the  patient  immune  against  the  inoculation  of  chan- 
croidal virus.     This,  however,  is  disputed. 

Frequency  of  Chancroids. — Chancroids  are,  in  hospital  practice  at 
least  (and  especially  in  Europe),  more  frequently  encountered  than  the 
chancre  :  hence  given  a  patient  with  suspicious  sores  about  the  geni- 


E'iG.  18. 


^•jl 


°4^i'4WI/W*W''-^ 


^"%'j^   «^ 


Multiple  chancroids  of  the  coronary  sulcus. 


Fin.  19. 


Chancroid  of  labium  major. 


Fig.  20. 


Exulcerating  or  superficial  chancroid 


Fig.  21. 


Follicular  chancroid. 


DISEASES   AND   INJUEIES   OF   THE   PENIS.  39 

talia,  the  odds  are  in  favor  of  such  sores  being  cliancroidal.  Such  a 
deduction  cannot  be  drawn  in  private  practice,  however,  since  in  all 
countries,  among  the  well-to-do,  the  chancre  is  more  frequently  seen 
than  is  the  soft  sore. 

Fournier  states  that  the  reason  for  this  is  that  the  hospital  patients 
are  poor,  ignorant,  and  uncleanly,  and  hence  careless  as  to  the  con- 
dition of  the  partners  in  their  indulgences.  The  well-to-do  are 
protected  from  chancroid  by  their  cleanliness  and  general  healthy 
condition,  and  by  the  fact  that  women  suffering  from  alesion  as  gross 
and  as  superficial  in  position  as  the  non-infecting  sore  could  prob- 
ably not  conceal  the  disease  from  them.  Moreover,  such  lesions 
in  the  better  class  of  prostitutes  would  be  immediately  subjected  to 
treatment. 

The  Localization  of  the  Chancroid. — The  chancroid  may  be  placed 
upon  any  cutaneous  or  exposed  mucous  surface.  It  is  usually  located 
on  or  about  the  genitaha.  Reported  cases  show  that  it  has  attacked 
the  mucous  membrane  of  the  mouth  and  nose,  the  conjunctiva,  the 
scalp,  and  the  fingers  ;  but  extragenital  chancroid  is  far  less  frequent 
than  extragenital  chancre. 

Genital  chancroids  in  the  male  are  usually  found  upon  the  glans 
and  the  prepuce.  The  favorite  position  is  at  or  near  the  frsenum,  in 
the  coronary  sulcus  (Fig.  18),  along  the  margin  of  the  prepuce,  on 
the  mucous  surfaces  of  the  glans  and  the  foreskin,  and  at  the  urethral 
orifice. 

In  females  these  lesions  are  found  along  the  margins  of  the  greater 
and  smaller  labia,  about  the  fourchette,  and  in  the  region  of  the 
urinary  meatus.    (Fig.  19.) 

Anal  chancroid  is  much  more  frequent  in  women  than  in  men. 
In  them  it  is  commonly  due  to  infection  of  cracks  or  fissures  about 
the  rectal  opening  by  the  contagious  discharge  which  flows  backward 
from  the  vulva.     The  chancroid  is  usually  multiple. 

The  extragenital  chancroids,  if  perigenital  lesions  be  excepted,  are 
rare.  The  history  of  inoculation  proves  that  such  lesions  are  possible, 
but  as  a  matter  of  clinical  experience  they  are  not  often  encountered. 
This  may  be  because  they  are  often  not  recognized. 

Pathology  of  Chancroid. — The  chancroidal  ulcer  is  made  up  of  a 
small  round-celled  mfiltrate,  somewhat  sharply  limited  in  depth,  but 
extending  considerably  beyond  the  borders  of  the  ulcer,  and  invading 
papillse  which  are  still  covered  M^th  apparently  healthy  epithelium. 
These  papillae  undergo  marked  hypertrophy. 

The  blood-vessels  are  dilated  and  increased  in  number,  and  ex- 
hibit in  the  adventitia  an  inflammatory  infiltration.     The  lymphatic 


40  GENITO-URINAEY   DISEASES    AND   SYPHILIS. 

vessels  are  also  abnormally  numerous,  and  open  directly  into  the 
ulcer.  If  one  of  these  vessels  is  injected  at  a  point  remote  from  the 
chancroid,  this  injection  will  flow  from  the  surface  of  the  sore. 
(Letzel.) 

The  Clinical  Aspects  of  Chancroid. — The  inoculation  chan- 
croid presents  the  lesion  in  its  typical  form. 

Inoculation  is  practised  by  moistening  the  point  of  a  scalpel  in 
chancroidal  discharge,  then  passing  this  point  perpendicularly  down 
to  the  true  skin,  rotating  the  knife  on  its  long  axis,  and  rubbing  in  as 
much  of  the  discharge  as  remains  on  the  sides  of  the  blade.  A  watch- 
crystal  placed  over  the  point  of  inoculation  and  held  in  place  by  straps 
allows  of  inspection  of  the  sore  in  all  the  phases  of  its  development. 

In  from  one  to  four  days  an  inflamed  pustule  develops,  which,  on 
rupture,  exposes  a  deep,  rounded,  ragged,  punched-out,  often  under- 
mined ulcer,  "v^dth  a  gray,  sloughing  surface.  This  ulcer  extends  for  a 
period  varying  from  one  to  three  weeks,  then  remains  stationary  for 
a  few  days,  and  finally  undergoes  resolution,  ultimately  healing  and 
leaving  a  cicatrix. 

Chancroid  as  acquired  by  coitus  differs  some^^hat  in  its  clinical 
aspects  from  that  caused  by  intentional  inoculation.  The  pustular 
stage  is  rarely  observed,  the  patient  not  detecting  the  lesion  until  an 
ulcer  has  developed,  since  the  chancroid  is  usually  so  placed  that  the 
thin  skin  covering  the  pustule  is  quickly  macerated.  The  acquired 
chancroid  frequently  seems  to  have  a  period  of  incubation  varjang 
from  three  to  seven  days ;  exceptionally  the  apparent  incubation  is 
much  longer ;  generally  this  is  because  the  sore  is  not  noticed  in  its 
early  stages.  Indeed,  it  is  not  uncommon  in  stripping  back  the  fore- 
skin to  expose  an  ulcer  which  is  at  least  several  days  old  and  of  the 
existence  of  which  the  patient  was  entirely  ignorant.  Ricord  explains 
these  cases  by  the  theory  that  the  virus  is  deposited  on  healthy  sur- 
faces, which  subsequently  becoming  eroded  offer  an  entrance-point  to 
the  micro-organisms. 

The  shape  of  the  chancroid  will  depend  upon  the  shape  of  the 
eroded  surface  through  which  inoculation  takes  place,  and  also  upon 
the  anatomical  peculiarities  of  the  part.  Thus,  inoculation  of  a  "  hair- 
cut" will  be  followed  by  a  linear  chancroid  ;  the  inoculation  of  an  ex- 
tensive abrasion  by  a  sore  corresponding  in  outlines  A\ith  this  abraded 
surface.  The  lesions  of  herpes  will  preserve  their  general  outline,  but 
will  take  on  chancroidal  ulceration.  An  infected  follicle  will  form 
first  a  hard,  rounded,  elevated  lesion  resembling  a  furuncle.  This 
rapidly  breaks  down  and  discharges,  exposing  a  characteristic  chan- 
croidal ulcer.    When  the  chancroid  involves  the  sides  of  the  frsenum 


DISEASES   AND    INJURIES   OF    THE    PENIS. 


41 


it  forms  a  long,  irregularly  shaped  lesion,  which  not  infrequently  causes 
complete  destruction  of  this  bridle.  When  it  is  placed  in  the  coronary 
sulcus  it  has  a  tendency  to  extend  in  the  direction,  of  this  furrow. 
When  it  attacks  the  anus  it  spreads  in  the  direction  of  the  skin-folds 
of  this  region. 

For  convenience  of  description  chancroids  are  frequently  named 
in  accordance  with  their  clinical  features.  Thus,  the  ectkymatous 
chancj'oid  is  one  characterized  by  the  formation  of  thick  crusts  ;  the 
exulcerating  chanoi^oid  is  one  which  remains  superficial  (Fig.  20) ;  the 
follicular  chancroid  is  one  which  primarily  involves  a  follicle,  re- 
sembling first  a  furuncle,  later 

producing  a  deep,  often  indu-  *'"•  ^^• 

rated  lesion  (Fig.  21) ;  the  idcus 
elevatum  is  one  which  is  raised 
from  the  surrounding  tissues, 
owing  to  a  more  than  usually 
abundant  inflammatory  infil- 
trate, which,  moreover,  may 
so  closely  simulate  the  hard- 
ness of  a  syphilitic  sore  as  to 
make  diagnosis  a  matter  of 
great  difficulty.  (Fig.  22.)  If 
from  lessened  tissue-resistance 
to  virulent  infection  there  is  ex- 
cited inflammation  more  acute 
than  is  commonly  observed, 
there  results  an  inflamed  chan- 
croid. If  this  inflammation  oc- 
casions rapid  extension  of  the 
lesions,  together  with  slough- 
ing of  surrounding  tissues,  the 
chancroid  is  termed  j^hagedenic. 
(Fig.  24.)  Where  this  tissue- 
destruction  is  both  rapid  and  extensive,  the  lesion  is  termed  gangrenous. 
When  the  chancroid  becomes  chronic,  spreading  slowly  and  reaching 
enormous  dimensions,  often  healing  in  one  part  while  it  is  extending 
in  another,  it  is  termed  serpiginous. 

Symptoms.— '{1)  There  is  no  period  of  incubation;  (2)  (he  lesions 
are  multiple ;  (3)  they  begin  as  pustules  or  ulcers  and  are  rapid  in 
their  course ;  (4)  they  form  ragged,  punched-out,  often  undermined 
ulcers,  irregular  in  shape,  discharging  freely,  inflammatory  in  type, 
and  covered  with  a  gray,  pus-soaked  slough,  which  may  be  concealed 


Indurateil  t'levated  chaatToid. 


42  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

by  a  thick,  moist  scab  (Fig.  23) ;  (5)  they  produce  similar  lesions  on 
surfaces  with  which  they  come  in  contact,  and  their  discharge  can  be 
inoculated  on  any  portion  of  the  surface  of  the  body  ;  (6)  they  are  not 
indurated ;  (7)  scrapings  from  their  surfaces  show  pus  and  shreds  of 
necrotic  tissue,  but  no  epithelium  ;  (8)  they  are  frequently  complicated 
by  inflammatory  bubo. 

A  positive  diagnosis  cannot  be  founded  on  any  one  of  these  charac- 
teristic features  of  the  sore,  but  must  rather  be  based  upon  associated 
symptoms.  Thus,  as  a  rule,  there  is  no  period  of  incubation,  yet 
there  are  many  reported  cases  in  which  such  a  period  apparently 
existed.  While  the  lesions  are  often  multiple,  this  is  by  no  means 
an  invariable  rule.  The  characteristic  feature  in  regard  to  the  multi- 
plicity of  chancroids  is  that  they  generally  appear  not  simultaneously, 
but  successively — i.  e.,  from  auto-inoculation ;  though  when  several 
abrasions  are  inoculated  at  the  same  time  the  multiple  lesions  will, 
of  course,  develop  coincidently. 

Though  the  disease  usually  begins  as  a  pustule  or  an  ulcer,  its  first 
manifestation  may  take  the  form  of  a  more  or  less  indurated  papule, 
in  which  acute  inflammatory  phenomena  may  progress  with  compara- 
tive slowness.  The  follicular  chancroid  sometimes  develops  in  this 
way.  Exceptionally  the  chancroid  appears  as  a  purely  superficial 
lesion,  the  nature  of  the  sore  in  this  case  not  being  suspected  until 
it  either  suddenly  assumes  typical  chancroidal  characteristics  or  by 
auto-inoculation  proves  its  true  nature. 

Auto-inoculation,  if  practised  after  the  virulent  stage  of  the  chan- 
croid is  passed,  will  not  succeed,  and  the  discharge  of  other  sores  ex- 
ceptionally produces  by  inoculation  lesions  not  unlike  those  caused 
by  chancroidal  pus. 

Sometimes  chancroids  are  indurated ;  this  is  particularly  true  of 
the  follicular  chancroid  and  of  those  sores  which  have  been  cauterized. 
Finally,  suppurating  buboes,  when  the  chancroids  are  seen  early  and 
are  carefully  treated,  are  the  exception  rather  than  the  rule. 

Hence  in  determining  the  nature  of  such  a  sore  the  general  symp- 
tom group  will  be  taken  rather  than  any  one  peculiarity,  and  upon 
this  an  opinion  will  be  given,  always  modified  by  the  knowledge  that, 
even  though  the  lesion  be  distinctly  chancroidal  in  type,  it  is  possible 
for  it  ultimately  to  develop  into  a  typical  chancre. 

What  might  be  called  the  natural  auto-inoculation — that  is,  the 
production  of  other  and  similar  sores  upon  healthy  surfaces  with 
which  the  first  lesion  comes  in  contact — is  one  of  the  strongest 
reasons  for  pronouncing  an  ulcer  chancroidal  in  nature,  since  this, 
though  possible,  rarely  takes  place  from  other  forms  of  ulceration. 


Fig.  23. 


Multiple  chancroids.    (Fox.) 


Fig.  24. 


Phagedenic  chancroid. 


Fig.  25. 


Chancroidal  bubo. 


DISEASES   AND   INJURIES    OP    THE    PENIS.  43 

Diagnosis — Chancroid  must  be  distinguished  from  chancre,  from 
herpes^  from  follicular  abscess,  from  erosions  of  balanitis  and  balanopos- 
thitis,  from  ulcerating  papular  syphilides,  from  ulcerating  gummata,  and 
from  tuberculous  ulcerations. 

The  distinction  between  the  soft  sore  and  the  chancre  is  one  which 
the  surgeon  most  frequently  will  be  called  upon  to  make,  and  is  some- 
times extremely  difficult ;  it  may,  indeed,  be  quite  impossible  to  formu- 
late  it.  The  typical  features  of  each  sore,  with  a  diagnostic  table, 
have  been  set  forth  in  another  part  of  this  work  (see  section  on  the 
primary  sore  of  syphilis),  but  it  is  not  amiss  to  call  attention  here  to 
the  fact  that  the  chancroid  may  be  indurated  whilst  the  chancre  may 
not  be.  In  the  chronic  chancroid  attacking  the  vulva  of  women,  the 
secondary  hardening  may  be  so  absolutely  like  that  of  the  primary 
lesion  of  syphilis  as  to  deceive  the  most  skilled.  Again,  chancroid 
may  cause  chronic  enlargement  of  several  of  the  inguinal  lymphatic 
glands,  thus  departing  from  its  type,  while  chancre  may  make  a  parallel 
variation  by  causing  suppurative  lymphadenitis. 

In  typical  cases  a  distinction  may  be  readily  made,  but  in  those 
Avhich  are  atypical  the  surgeon  should  not  commit  himself  to  a  positive 
opinion,  since  even  so  skilled  a  syphilographer  as  Fournier  acknow- 
ledges that  he  has  been  deceived. 

The  mixed  chancre — that  is,  the  lesion  resulting  from  inoculation 
with  chancroidal  virus  and  the  virus  of  syphilis  at  the  same  point — 
can  be  properly  diagnosed  only  after  prolonged  observation :  hence, 
even  though  the  sore  conform  absolutely  to  the  chancroidal  type,  ii,  is 
not  safe  to  assert  on  first  inspection  that  syphilitic  infection  has  :ioc 
taken  place. 

The  lesions  of  hei-pes,  follicular  abscess,  the  erosions  of  balanitis  and 
balanoposthitis,  or  mechanical  abrasions  may  readily  be  mistaken  for 
chancroids  when  they  first  appear.  In  a  few  days,  at  most,  the  super- 
ficial nature  of  the  inflammation  and  the  prompt  yielding  to  cleansing 
applications  show  that  chancroidal  infection  is  absent. 

Ulcerating  papular  syphilides  when  found  upon  the  genitalia  closely 
resemble  chancroids,  but  are  more  slow  in  their  course,  are  less  in- 
flammatory in  type,  and  exhibit  other  lesions  of  the  disease  ;  on  exami- 
nation of  the  patient  a  history  of  preceding  syphilitic  infection  usually 
may  be  elicited. 

Ulcerating  gummata  of  the  genitalia  produce  lesions  indistinguish- 
able in  appearance  from  chancroids.  Here,  again,  however,  a  history  of 
syphilis,  the  development  of  a  tumor  preceding  ulceration,  the  slow  prog- 
ress of  the  lesion,  the  absence  of  the  symptoms  of  acute  inflammation, 
and  the  effect  of  constitutional  treatment  will  lead  to  a  correct  diagnosis. 


44  GENITU-UEINAKY   DISEASES   AND   SYPHILIS. 

Tuberculous  ulcers  are  extremely  rare  ;  they  cannot  be  distinguished 
from  chancroidal  lesions  by  inspection  alone.  They  have,  however, 
a  history  of  very  slow  extension,  are  usually  associated  with  tuber- 
culous lesions  in  other  parts  of  the  body,  sometimes  exhibit  about  the 
periphery  of  the  ulceration  grayish,  semi-transparent,  miliary  tuber- 
cles, and  on  microscopic  examination  of  the  scrapings  of  the  lesion 
often  show  the  tubercle  bacillus.  Moreover,  inoculation  on  guinea- 
pigs  will  after  a  time  disclose  the  true  nature  of  the  lesion. 

Sometimes  a  differential  diagnosis  can  be  made  only  by  auto- 
inoculation, — a  valuable  means  of  determining  the  presence  or  ab- 
sence of  the  chancroidal  virus,  but  one  which  is  not  infallible,  its 
value  is  perhaps  best  formulated  by  stating  that  the  majority  of  chan- 
croids will  produce  ulcers  of  a  similar  type  on  inoculation,  while  the 
majority  of  other  ulcers,  either  syphilitic^  tuberculous,  or  inflammatory, 
will  not  produce  such  lesions. 

COMPLICATIONS  OF  CHANCROID. 

1.  Phimosis  and  paraphimosis ;  2,  Excessive  inflammation,  phage- 
dagna,  and  gangrene  ;  3,  Lymphangitis  and  lymphadenitis. 

Of  all  these  complications  lymphadenitis,  or  bubo,  is  by  far  the 
most  common. 

Phimosis. — This  forms  a  serious  complication  of  chancroid, 
mainly  because  it  prevents  the  ulcer  from  being  efficiently  treated 
and  causes  retention  of  discharge,  and  consequently  favors  the  occur- 
rence of  acute  inflammation  and  the  formation  of  inguinal  buboes. 

Sometimes  a  chancroid  develops  upon  the  glans  penis  or  the  inner 
preputial  surface  in  cases  congenitally  phimotic.  More  frequently  phi- 
mosis is  occasioned  by  the  swelling  incident  to  the  lesion, — a  long, 
easily  retracted  foreskin  becoming  from  oedema  and  infiltration  so 
thickened  and  the  preputial  orifice  so  narrow  that  retraction  is 
impossible.  If  the  chancroid  is  placed  upon  the  outer  surface  of 
the  prepuce  this  complication  is  of  slight  moment,  usually  yielding 
quickly  to  treatment.  When,  however,  the  sore  is  concealed  and 
rendered  inaccessible  by  the  swelling,  a  vicious  circle  is  estabMshed, 
which  may  be  productive  of  the  most  serious  consequences.  The  irri- 
tation incident  to  retained  and  decomposing  discharges  increases  the 
inflammatory  swelling,  renders  the  phimosis  still  more  complete,  and 
by  interfering  with  circulation  weakens  tissue-resistance,  so  that  the 
lesion  rapidly  extends,  a  ring  of  inoculation  chancroids  often  develop- 
ing about  the  preputial  orifice.  (Fig.  26.)  In  severe  cases  extensive 
sloughing  and  gangrene  occur.  The  foreskin  becomes  dark,  almost 
black,  cold,  non-resisting,  and  finally  melts  down  at  one  or  more 


DISEASES   AND    INJURIES   OF   THE    PENIS. 


45 


points  into  a  putrid,  pultaceous  mass.  This  gangrenous  process  may 
attack  also  the  glans  penis,  and  partly  or  totally  destroy  it. 

Diagnosis. — The  diagnosis  of  subpreputial  chancroid  is  founded 
upon  the  severity  of  the  inflammatory  symptoms,  upon  their  persist- 
ence, or  even  their  aggravation,  in  spite  of  careful  treatment,  and 
upon  the  result  of  auto-inoculation.  At  times  palpation  will  elicit 
local  tenderness,  and  the  inflammatory  induration  of  the  lesion  may 
be  recognized  by  touch  through  the  foreskin. 

Herpes  and  balanoposthitis  rarely  occasion  as  active  local  symp- 

FiG.  26. 


Chancroidal  phimosLS.    Secondary  chancroids  about  the  preputial  orifice. 

toms  as  does  chancroid.  The  discharge  is  moderate ;  the  uedema  is 
not  excessive  ;  cleansing  treatment  quickly  cures. 

Concealed  chancre  occasions  moderate  swelling,  can  be  felt  as 
an  indurated  plaque  or  nodule,  and  is  accompanied  by  the  inguinal 
adenitis  and  other  symptoms  of  chancre. 

Gonorrhoeal  phimosis,-  usually  associated  with  balanoposthitis,  will 
show  in  the  discharge  the  gonococci,  and  will  be  accompanied  by 
ardor  urinae,  felt  along  the  urethra,  by  chordee,  and  by  the  other  symp- 
toms of  gonorrhcea.  It  must  not  be  forgotten  that  both  gonorrhoea 
and  chancroid  may  be  present. 


46  &EN1T0-UKINAKY   DISEASES   AND   SYPHILIS. 

Treatment — In  the  case  of  chancroid  complicated  by  phimosis  re- 
quiring circumcision,  ether  should  be  given,  the  parts  should  be 
repeatedly  disinfected,  but  not  by  the  operator  or  his  assistant, 
nor  should  any  of  the  basins  or  solutions  be  used  which  are  sub- 
sequently to  be  employed  during  the  operation  ;  the  foreskin  should 
then  be  split  to  an  extent  just  sufficient  to  allow  of  thorough  cau- 
terization with  the  Paquelin  cautery  of  all  the  chancroids  and  of  the 
wound  made  in  splitting.  All  the  towels  surrounding  the  penis,  and 
the  solutions  and  basins  used  in  former  washings  are  removed.  The 
seat  of  operation  is  surrounded  with  a  fresh  sterile  or  wet  bichlo- 
ride towel,  the  glans  and  foreskin  are  put  through  a  vigorous  course 
of  cleansing  with  fresh  solutions  from  a  clean  set  of  basins  by  the 
surgeon  and  his  assistants,  and  the  circumcision  is  performed.  The 
coaptation  should  be  exact.  A  wet  dressing  is  applied,  preferably 
the  gauze  bandage  wrung  out  of  dilute  lead  water  and  alcohol  equal 
parts,  and  the  patient  is  kept  in  bed  for  five  days,  with  the  penis  and 
scrotum  supported  by  a  pillow  of  antiseptic  cotton  covered  with  gauze. 
Often,  in  spite  of  every  precaution,  the  entire  circumcision  wound 
becomes  chancroidal.  When  redness,  swelhng,  and  suppuration  at 
one  or  more  points  foretell  this,  the  stitches  must  be  taken  out,  and 
the  wound  dressed  several  times  daily,  as  described  under  chancroid. 

Paraphimosis. — Patients  with  congenitally  short  prepuces,  or 
those  whose  foreskins  are  habitually  retracted,  frequently  suffer  from 
paraphimosis  incident  to  the  swelling  occasioned  by  chancroid  ;  or  this 
condition  may  result  from  retraction  of  the  foreskin  after  the  swelling 
is  well  advanced,  as  it  is  then  often  impossible  to  draw  it  forward. 
This  complication  is  much  less  troublesome  than  phimosis,  since  the 
lesion  is  exposed  and  can  be  properly  treated.  It  occasions,  how- 
ever, more  rapid  and  dangerous  congestion  than  phimosis,  and  usually 
demands  immediate  relief. 

Gangrene — Phagedaena. — Chancroids  may  be  unusually  inflam- 
matory in  type  from  the  first,  or  after  a  comparatively  mild  course 
may  suddenly  become  acutely  inflamed. 

The  causes  of  this  are  usually  a  general  cachectic  condition^  local 
irritation^  either  mechanical,  as  from  coitus,  or  chemical,  as  from  filth, 
decomposing  discharges,  and  irritating  applications,  and  disturbances  of 
circulation,  as  from  phimosis  and  paraphimosis. 

In  these  cases  swelling  and  redness  extend  far  beyond  the  lesion 
and  the  whole  involved  part  becomes  oedematous.  The  patient  com- 
plains of  pain,  there  is  often  a  mild  inflammatory  fever,  and  the  ulcer 
rapidly  spreads. 

If  the  causes  producing  inflammation  remain  still  operative  and 


DISEASES   AND   IN^JITRIES   OF    THE    PENIS.  47 

piuinpt  treatment  is  not  applied,  the  lesion  becomes  gangrenous ;  in 
this  case  swelhng  is  more  pronounced,  and  large  areas  become  dusky 
red,  dirty  brown,  and  finally  quite  black  and  putrid.  In  a  very  few 
hours  extensive  tissue-destruction  may  result.  The  entire  penis  may 
be  destroyed,  the  testicles  may  be  laid  bare,  and  the  process  may 
extend  far  up  the  belly-walls.  The  constitutional  symptoms  are 
pronounced. 

At  times  the  destructive  process  is  much  slower  in  its  course,  ulti- 
mately producing  lesions  quite  as  extensive,  but  rather  by  molecular 
death.  The  ulcer  steadily  extends,  in  spite  of  treatment,  until  it 
attains  enormous  dimensions,  exposing  the  blood-vessels  of  the  groins, 
destroying  the  entire  scrotum,  eating  far  back  along  the  perineum,  and 
leaving  but  the  stump  of  the  penis.  This  process  is  termed  phage- 
denic^ and  is  never  observed  except  in  those  whose  systems  are  pro- 
foundly depressed.  Thus  it  is  encountered  in  diabetics,  or  in  those 
suffering  from  scurvy  or  scrofula,  from  visceral  diseases,  such  as  chronic 
hepatitis  and  nephritis,  or  from  tertiary  syphilis. 

The  phagedenic  ulcer  sometimes  lasts  for  months  or  years,  mani- 
festing a  tendency  to  heal  in  one  part  whilst  it  steadily  extends  in 
another,  the  lines  of  extension  often  having  a  circinate  or  serpentine 
outline.     This  form  of  ulceration  is  termed  serpiginous. 

Lymphangitis,  or  inflammation  of  the  lymphatic  vessels,  is  a 
rare  complication  of  chancroid  ;  even  though  suppurating  buboes  de- 
velop, the  lymphatic  vessels  which  carry  the  irritating  substance  from 
the  ulcers  to  the  glands  are  generally  spared.  When  they  are  in- 
volved there  is  formed,  usually  on  the  dorsum  of  the  penis,  a  tender, 
indurated  cord,  over  which  the  skin  is  reddened.  The  perivascular 
tissues  become  infiltrated  and  oedematous,  and  there  may  be  consider- 
able swelling  of  the  subcutaneous  tissues.  Resolution  usually  takes 
place  under  appropriate  treatment.  Exceptionally  suppuration  occurs. 
At  one  or  more  points  the  swelling  is  more  marked,  the  skin  is  ad- 
herent and  bluish  red,  fluctuation  is  detected,  and  an  abscess  forms. 
This  opening  usually  heals  kindly ;  but  sometimes  it  is  converted  into 
a  chancroid. 

Bubo,  or  lymphadenitis,  as  has  been  stated,  is  the  commonest 
complication  of  chancroid.  The  number  of  cases  suffering  from  this 
complication  varies,  according  to  different  reports,  from  five  per  cent, 
to  thirty  per  cent,  of  the  total  number  suffering  from  chancroid.  In 
hospital  practice  about  one  out  of  five  ambulant  chancroid  cases  de- 
velop bubo ;  in  office  practice  and  among  the  well-to-do  this  compli- 
cation is  comparatively  rare.  This  is  because  intelligent  people  detect 
the  sore  early  and  have  it  treated.     The  glands  involved  are  generally 


48  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

those  to  which  the  lymph-vessels  supplying  the  seat  of  ulceration  pass 
most  directly, — i.e.,  the  group  of  glands  lying  below  Poupart's  liga- 
ment, above  the  saphenous  opening.  The  glands  lying  near  the 
middle  line  of  the  body  to  the  right  and  left  of  the  symphysis  pubis 
generally  escape.  Adenitis  from  lesions  of  the  foot  or  leg  attacks 
primarily  the  glands  lying  just  below  the  saphenous  opening  in  the 
course  of  the  long  saphenous  vein. 

It  is  usual,  in  cases  of  sores  on  the  genitalia,  for  bubo  to  form  on 
the  side  of  the  body  corresponding  with  that  of  the  lesion.  This  rule 
is  at  times  reversed,  sores  on  the  right  side  of  the  penis,  for  instance 
causing  suppurating  bubo  in  the  left  groin.  Lesions  of  the  fraenum 
frequently  cause  double  buboes, — that  is,  involvement  of  lymphatics 
in  both  groins, — and,  indeed,  sores  of  this  region  and  upon  the  pre- 
puce and  glans  are  followed  by  a  larger  percentage  of  buboes  than 
when  the  chancroids  are  located  on  any  other  part  of  the  genitalia. 

In  patients  of  a  tubercular  tendency  frequently  the  entire  lymphatic 
chain  of  glands  slowly  enlarges,  forming  a  lobulated  tumor,  sometimes 
the  size  of  a  man's  fist.  Softening  and  disintegration  take  place 
slowly,  and  if  the  case  is  untreated  fistulne  will  form,  which  may  last 
for  months  or  years. 

The  bubo  is  generally  single  and  unilateral ;  it  may  be  multiple 
and  bilateral. 

Cause. — Aside  from  the  fact  that  retained  discharges  distinctly  pre- 
dispose to  bubo,  the  character  of  the  sore  seems  to  have  little  influ- 
ence in  the  development  of  this  comphcation.  Thus  a  sloughing  or 
gangrenous  chancroid  will  run  its  course  without  any  effect  upon  the 
lymphatic  glands,  while  a  superficial  lesion  the  size  of  a  split  pea  may 
be  accompanied  by  a  double  suppurating  lymphadenitis. 

This  comphcation  usually  develops  from  the  second  to  the  fourth 
week  of  the  chancroid.  It  may,  however,  appear  almost  as  soon  as 
the  lesion,  or  may  develop  weeks  after  the  chancroid  has  been  com- 
pletely cicatrized. 

The  direct  cause  of  bubo  is  not  clearly  formulated.  It  has  not  been 
demonstrated  that  the  destructive  adenitis  is  invariably  due  to  the 
action  of  micro-organisms  upon  the  gland.  Cultures  and  auto-inocu- 
lations made  with  the  discharge  of  buboes  give  negative  results,  and 
microscopic  examination  of  such  discharge  may  fail  to  show  bacteria. 
The  degeneration  of  the  glands  is  probably  owing  partly  to  the  pres- 
ence of  a  chemical  irritant  absorbed  from  the  ulcerating  surface. 

Symptoms.— The  bubo  usually  begins  with  a  sense  o\  pain  on 
motion  referred  to  the  inguinal  region.  On  examination  there  is 
found  a' hard,  tender  lump  over  which  the  skin  is  freely  movable. 


DISEASES    AND    INJURIES    OF    THE    PENIS.  49 

This  lump  steadily  increases  in  size,  becomes  constantly  painful,  and 
is  so  tender  that  the  patient  is  confined  to  his  chair  or  bed.  The 
overlying  skin  becomes  reddened,  adherent,  and  oedematous.  The 
patient  complains  of  rigors,  fever,  and  thirst,  and  finally  on  examina- 
tion fluctuation  is  detected. 

The  pain  may  be  constant  and  almost  unbearable ;  sometimes 
Avithout  obvious  cause  it  is  suddenly  relieved.  This  is  due  to  rupture 
of  the  gland  capsule  and  escape  of  its  contents  into  the  surrounding 
tissue,  and  is  followed  by  rapid  increase  of  sv^elling  and  breaking 
down  of  the  periglandular  tissues. 

On  evacuation  of  the  suppurating  bubo,  thick,  blood-stained  pus  is 
discharged,  leaving  a  cavity  with  gray  and  necrotic  walls.  On  digital 
examination  of  this  cavity  it  is  often  possible  to  detect  several  swollen 
glands  which  have  been  involved  in  the  inflammatory  process  but 
have  not  yet  been  completely  destroyed.  These  are  felt  projecting 
into  the  space  from  which  the  pus  has  been  evacuated. 

If  the  abscess  is  untreated,  the  pus  often  burrows  in  various 
directions,  forming  long  sinuses  before  spontaneous  evacuation  takes 
place.  These  seriously  compHcate  the  subsequent  course  of  the 
affection. 

Usually,  after  evacuation  of  the  pus  and  proper  surgical  treatment 
of  the  resulting  cavity,  healing  takes  place  promptly.  In  such  cases 
the  lesion  is  said  to  be  a  simple  bubo.  Exceptionally  soon  after  open- 
ing the  bubo  its  whole  surface  becomes  converted  into  a  huge  ulcer 
corresponding  in  type  with  chancroid.  This  is  termed  the  chancroidal 
bubo.  (Fig.  25.)  Appropriate  treatment,  however,  shortly  converts 
this  into  a  simple  ulcer,  which  ultimately  heals  kindly,  though,  as  in 
the  case  of  the  chancroid  itself,  inflammation,  gangrene,  or  phagedsena 
may  complicate  the  healing.  It  is  probable  that  the  bubo  is  never 
primarily  chancroidal,  but  becomes  so  by  inoculation  either  during 
or  after  operation. 

In  women  buboes  rarely  complicate  chancroids.  When  they 
occur  they  are  generally  found  in  the  inguinal  region,  the  lymphatic 
vessels  about  the  vulva  and  the  rectum  communicating  with  the 
glands  of  the  groin. 

Prognosis. — The  chancroid  as  it  occurs  in  healthy  people,  and 
especially  in  those  who  are  cleanly  in  their  habits  and  who  will  scru- 
pulously follow  a  mild  antiseptic  treatment,  runs  its  course  in  from 
three  to  six  weeks  without  complication.  Even  if  no  treatment  what- 
ever is  applied,  the  majority  of  chancroids  will  heal  spontaneously 
in  six  weeks.  During  the  whole  course  of  the  lesion,  and  even  after 
cicatrization  has  taken  place,  buboes  may  form,  and  prognosis  as  to 

4 


oO  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

the  avoidance  of  this  coiiipHcation  should  be  extremely  guarded. 
Except  in  the  most  superficial  forms,  the  lesion  is  followed  by 
scarring. 

TREATMENT   OF   CHANCROID. 

Since  it  is  pretty  generally  conceded  that  chancroid  is  due  to 
inoculation  with  the  discharge  of  a  simJlar  lesion,  and  since  such 
inoculation  takes  place  almost  invariably  by  sexual  congress,  the  pro- 
phylaxis of  chancroid  is  comparatively  simple.  Where,  however,  this 
means— i.e.,  avoidance  of  exposure — is  not  adopted,  careful  and  thor- 
ough washing  with  weak  antiseptics,  particular  attention  being  devoted 
to  the  folds  of  skin  in  the  region  of  the  fraenum,  and  the  treatment  of 
abrasions  by  means  of  strong  solutions  of  mercury  bichloride  or  of 
carbolic  acid,  1  to  200  of  the  former,  1  to  10  of  the  latter,  will  nearly 
always  prevent  the  appearance  of  chancroid.  These  solutions  should 
be  applied  directly  to  the  abrasions  by  means  of  a  small  cotton  swab, 
and  should  not  be  employed  as  lotions  for  the  entire  penis. 

Whatever  form  of  treatment  is  adopted,  the  end  to  be  attained  is 
the  conversion  of  the  unhealthy  spreading  ulcer  into  a  healing,  granu- 
lating surface.  Since  the  virulent  properties  of  the  chancroid  are 
dependent  upon  the  presence  of  micro-organisms,  it  necessarily  fol- 
lows that  efficient  treatment  must  have  for  its  end  either  an  inhibitory 
or  a  destructive  action  upon  these  micro-organisms,  or  must  so  in- 
crease the  local  resistance  that  the  lesion  cannot  spread.  Antiseptics 
in  some  form  are  indicated.  These  should  be  either  so  mild  that 
they  produce  little  or  no  irritation,  or  so  powerful  that  they  cause  total 
destruction  of  the  entire  diseased  area, — i.e.,  they  should  be  distinctly 
cauterant. 

Under  the  application  of  mild  antiseptics  the  chancroid  is  usually 
cured  in  from  two  to  six  weeks.  Under  the  apphcation  of  cauterants 
a  cure  sometimes  results  in  from  seven  to  fourteen  days. 

Satisfactory  results  may  be  obtained  by  the  observance  of  surgical 
cleanliness,  not  only  of  the  surface  of  the  sore,  but  also  of  the  sur- 
rounding skin  or  mucous  membrane.  After  thorough  washing  with 
soap  and  hot  water,  a  spray  of  hydrogen  peroxide,  full  strength,  is 
directed  on  the  chancroid  and  the  skin  near  it :  this  is  followed  by 
washing  or  spraying  with  carbolic  1  to  60  or  bichloride  1  to  3000. 

After  the  chancroid  and  the  surrounding  surfaces  have  been 
cleansed,  the  surgeon  may  conduct  the  treatment  with  either  non- 
irritating  antiseptic  applications  or  with  cauterants. 

NoN-iRRiTATiNG  ANTISEPTIC  APPLICATIONS  may  be  made  in  the  form  of 
powders,  of  ointments,  or  of  lotions. 


DISEASES   AND   INJURIES   OF    THE    PENIS.  51 

Dry  Dressings. — The  powders  commonly  employed  are  iodoform, 
aristol,  iodol,  boric  acid,  calomel,  acetanilid,  zinc  stearate,  zinc  oxide, 
and  bismuth  subnitrate.  None  of  these  are  strongly  antiseptic.  The 
most  efficient  is  iodoform ;  this  has  practically  no  antiseptic  value, 
but  in  the  presence  of  pus  undergoes  decomposition,  the  products 
of  which  render  ptomaines  inert  and  have  a  distinct  inhibitory  effect 
upon  further  germ-growth.  The  objections  to  the  use  of  the  drug 
are  its  penetrating  odor  and  occasionally  the  production  of  violent 
inflammation.  The  odor  may  be  in  part  disguised  by  mixing  with 
the  powder,  in  the  proportion  of  a  drop  to  a  drachm,  oil  of  lavender 
or  attar  of  roses,  or  finely  pulverized  coffee  in  the  proportion  of  one 
part  to  five  may  be  added  to  the  iodoform.  None  of  these  expedients 
will  be  found  perfectly  satisfactory. 

In  applying  this  powder  it  is  important  to  bring  it  directly  in  con- 
tact with  the  ulcerating  surface  ;  when  it  is  placed  upon  the  surround- 
ing skin  or  upon  crusts  covering  lesions  it  is  absolutely  useless,  except 
to  intensify  the  odor.  It  can  be  dusted  upon  the  cleansed  lesion  by 
means  of  a  small  pledget  of  cotton  which  is  first  rubbed  in  the  pow- 
der, or  by  an  insufflator,  or  in  the  form  of  a  spray  of  iodoform  in  ether. 
It  should  be  used  only  after  the  lesion  has  been  thoroughly  cleansed 
by  hydrogen  peroxide  and  dilute  antiseptics. 

Iodol  and  aristol  have  similar  properties,  but  are.  more  prone  to 
form  crusts,  thus  favoring  retention  of  discharge.  In  clinical  practice 
they  have  been  found  distinctly  less  efficient  than  iodoform. 

Zinc,  calomel,  and  bismuth  are  mainly  efficient  as  drying  agents, 
though  they  undoubtedly  have  feeble  astringent  and  antiseptic  prop- 
erties. 

In  the  application  of  dusting-powders  they  should  never  be  allowed 
to  form  with  the  secretions  scabs  or  crusts,  thus  preventing  the  escape 
of  discharges,  and  they  should  be  brought  immediately  in  contact  with 
granulating  surfaces.  Boric  acid  and  salicylic  acid  are  sometimes 
useful  as  dusting  powders,  and  are  less  prone  thus  to  form  crusts  than 
the  insoluble  preparations.  Salicyhc  acid  is  often  so  irritating  that 
its  application  is  not  advisable,  especially  as  its  antiseptic  powers  are 
limited. 

If  dry  dressings  are  used,  the  lesion  is  treated  from  one  to  six 
times  a  day  in  accordance  with  the  amount  of  discharge.  It  is  first 
cleansed,  then  dried  by  means  of  absorbent  cotton,  then  dusted  with 
the  remedy  of  choice ;  finally  a  thin  sheet  of  absorbent  cotton  is  laid 
over  it,  and  is  retained  in  position  by  straps  or  bandages,  or  by  pulling 
the  foreskin  forward. 

Dry   dressing   is   indicated    in    chancroids  of   moderate   severity 


52  GENITO-UPaNARY    DISEASES   AND   SYPHILIS. 

which  are  not  inflammatory  in  type  and  which  do  not  discharge 
profusely. 

Wet  Dressings. — In  place  of  the  dusting  powders,  after  thorough 
cleansing  of  the  lesions  and  surrounding  parts  there  may  be  placed  on 
the  ulcerating  surface  pledgets  of  cotton  wet  in  one  of  a  variety  of  mild 
antiseptic  lotions.  Of  these  the  most  efficient  are  carbolic  acid  1  to  60, 
bichloride  1  to  3000,  zinc  sulphate  1  to  60,  copper  sulphate  1  to  60, 
phenol  sodique  1  to  6,  dilute  lead  water.  These  wet  cotton  pledgets 
should  be  changed  frequently,  especially  when  the  discharge  is  abun- 
dant. This  is  readily  managed,  since  the  patient  can  carry  with  him  a 
small  bottle  of  the  antiseptic  solution  and  some  cotton.  He  should 
change  the  cotton  pledget  each  time  he  urinates.  The  dressmg  is 
kept  in  place  by  the  foreskin  in  many  cases,  or  by  straps,  bandages, 
jock-straps,  or  swimming-tights. 

The  wet  dressing  is  especially  indicated  in  patients  whose  incli- 
nation or  surroundings  prevent  them  from  carrying  out  the  careful 
cleansings  required  in  dry  dressings,  and  in  patients  whose  lesions 
discharge  freely  and  are  inflammatory  in  type. 

Antiseptic  Ointments. — Ointments  employed  in  the  treatment  of 
chancroid  have  for  their  active  principle  a  drug  such  as  iodoform,  boric 
acid,  salicylic  acid,  carbolic  acid,  or  one  of  a  large  variety  of  similar 
antiseptics.  They  are  most  useful  when  there  is  a  tendency  to  form 
crusts,  and  when  the  lesions  are  cicatrizing. 

Cauterization. — Immediate  and  complete  destruction  of  a  chan- 
'croidal  ulcer  is  the  safest  routine  treatment,  since  thus  its  virulent 
qualities  are  immecUately  destroyed  and  there  results  a  healthy  granu- 
lating surface  which  quickly  cicatrizes,  and  which,  if  kept  clean,  is 
attacked  only  in  very  exceptional  circumstances  by  the  complications 
characteristic  of  chancroid.  The  main  objection  urged  against  this 
method  of  treatment  is  that  it  is  unnecessarily  severe,  since  the  majer- 
ity  of  chancroids  will  heal  kindly  under  simple  antiseptic  dressings. 
This  argument  obtams  particularly  among  the  well-to-do,  who,  by  care- 
ful observance  of  treatment,  usually  recover  promptly.  In  dispensary 
patients,  however,  and  in  those  who  are  careless,  or  who,  from  their 
surroundings,  cannot  treat  chancroids  in  accordance  with  the  principles 
of  surgical  cleanliness,  cauterization  is  particularly  to  be  commended. 

For  cauterizing  chancroids,  nitric  acid,  sulphuric  acid,  caustic  pot- 
ash, bromine,  iodine,  zinc  chloride,  copper  sulphate,  arsenous  acid, 
and  the  actual  cautery  have  all  been  successfully  employed. 

The  best  instrument  for  destroying  chancroids  is  the  actual  cau- 
tery ;  this  may  be  used  in  the  form  of  a  heated  iron,  Paquelin's 
cautery,  or  the  galvano-cautery. 


DISEASES   AND   INJURIES   OF   THE    PENIS.  53 

In  performing  the  operation  the  chancroid  and  the  surrounding 
healthy  area  are  first  thoroughly  cleansed,  and  are  then  anaesthetized 
by  means  of  a  spray  of  ten  per  cent,  solution  of  cocaine  directed 
against  the  ulcerating  surface  and  by  hypodermic  injection  of  ten 
drops  of  a  one  per  cent,  solution  of  eucaine  driven  into  the  cellular 
tissue  surrounding  the  base  of  the  lesion.  The  cautery  at  a  white  heat 
is  then  applied,  so  that  not  only  the  chancroid  is  destroyed,  but  also 
the  surrounding  tissue  to  the  extent  of  one-eighth  of  an  inch  from  the 
borders  of  the  sore.  The  cautery  must  be  carried  to  every  recess  of 
the  ulcer.  If  sinuses  are  present,  these  must  be  slit  up  and  their 
unhealthy  walls  cauterized.  If  the  minutest  portion  of  the  sore  is 
left  untouched  by  the  cautery,  the  probability  is  that  the  entire  lesion 
produced  by  the  operation  will  again  become  infected.  After  cau- 
terizing, the  chancroid  and  the  surrounding  parts  should  again  be 
thoroughly  disinfected.  The  dry  eschar  resulting  from  the  burning  is 
dusted  with  iodoform  and  protected  by  the  application  of  a  little  ab- 
sorbent cotton.  In  from  three  to  five  days  this  eschar  comes  away, 
exposing  a  healthy  ulcer,  which  quickly  cicatrizes. 

Inflammatory  swelling  resulting  from  this  application  is  combated 
by  the  application  of  strips  of  lint  wrung  out  of  dilute  lead  water,  or 
dilute  lead  water  and  alcohol  equal  parts,  and  kept  constantly  wet 
with  this  solution. 

In  case  the  actual  cautery  cannot  be  employed,  nitric  acid  is  gen- 
erally used.  This  is  applied  by  means  either  of  a  glass  rod  or  of  a 
pledget  of  cotton  wrapped  on  a  wooden  applicator.  It  is  thoroughly 
rubbed  into  the  chancroid  and  carried  a  little  wide  of  the  ulcerating 
surface.  The  dressing  in  this  case  is  the  same  as  that  applied  after 
the  use  of  the  actual  cautery. 

Caustic  potash,  iodine,  and  other  cauterants  are  employed  in  the 
same  way. 

Cauterization  is  indicated  when  chancroids  are  seen  in  their  early 
stages,  when  they  are  rapidly  extending,  and  when  they  are  gangrenous, 
phagedenic,  or  serpiginous. 

Cauterization  is  contra-indicated  when  the  inflammatory  swelling 
incident  to  its  use  would  probably  occasion  phimosis  and  paraphimo- 
sis, when  the  chancroid  is  markedly  inflamed  but  not  yet  sloughing 
extensively,  and  when  the  lesion  has  passed  through  its  virulent  stag-e 
and  is  healing. 

Operation. — Two  operations  have  been  suggested  and  carried  out 
in  the  hope  of  accomplishing  the  immediate  cure  of  chancroid. 

The  first  requires  a  thorough  curetting  of  the  lesion,  careful  anti- 
septic washing,  and  dusting  with  iodoform  powder. 


54 


GEi^ITO-UKIJ^ARY   DISEASES   AJ^D   SYPHILIS. 


The  second  requires  excision  of  the  lesion  and  immediate  suture 
of  the  resulting  wound. 

If  reports  of  cases  can  be  accepted  as  conclusive  'evidence  in  favor 
of  any  treatment,  these  operations  should  be  universally  adopted. 
Our  experience,  however,  has  not  corroborated  the  favorable  opinion 
of  these  methods  advanced  by  others. 

Treatment  of  the  Complications  of  Ohancroid. — Phimosis. 
— When  the  subpreputial  chancroid  is  compKcated  by  phimosis,  ef- 
ficient treatment  is  rendered  difficult  bv  the  fact  that  the  sore  is  not 


Fig.  27 


Chancroidal  ulceration  of  an  incision  of  the  prepuce  required  iuT  the  relief  of  ijhimosis. 


readily  accessible  and  by  the  retention  of  discharge  ;  consequently 
such  lesions  are  prone  to  become  inflammatory  in  type,  to  excite 
oedema  and  congestion,  to  develop  phagedenic  or  gangrenous  symp- 
toms, and  to  be  complicated  by  buboes.  When  the  symptoms  of 
inflammation  are  moderately  severe,  satisfactory  results  may  be  ob- 
tained by  the  frequent  employment  of  mild  antiseptic  subpreputial 
washes  and  the  external  application  of  evaporating  lotions.  Thus 
the  whole  preputial  sac  may  be  syringed  out  every  two  hours  with 
hydrogen  peroxide,  followed  by  mild  bichloride  solution  1  to  6000,  or 


DISEASES   AND    INJURIES    OF   THE    PENIS.  55 

other  unirritating  antiseptic.  The  penis  should  be  kept  elevated,  so 
that  venous  congestion  may  be  diminished,  and  should  be  v^rapped 
in  lint  kept  wet  with  alcohol  and  lead  water  equal  parts  of  each  ;  or, 
when  the  circumstances  of  the  patient  are  such  as  to  permit  this 
treatment,  subpreputial  washes,  followed  by  prolonged  soaking  of  the 
penis  in  water  as  hot  as  can  be  borne,  are  at  times  most  efficacious 
in  reducing  inflammation.  The  soaking  should  last  for  an  hour,  and 
should  be  repeated  three  or  four  times  daily. 

If,  despite  this  treatment,  swelhng  rapidly  increases,  and  it  is  evi- 
dent that  the  chancroid  is  steadily  extending,  there  should  be  no  hesi- 
tation in  splitting  the  prepuce  along  the  dorsum,  exposing  the  chancroid, 
cleansing  it  carefully,  and  thoroughly  cauterizing  it.  The  cautery  iron 
should  also  be  carried  along  the  preputial  incision,  since  otherwise  this 
fresh  wound  would  probably  become  infected  and  form  a  chancroid 
as  virulent  in  type  as  that  for  the  relief  of  which  the  operation  was 
required.  (Fig.  27.)  The  objection  to  performing  circumcision  at 
this  time  hes  in  the  fact  that  the  operation  wound  is  usually  con- 
verted into  a  chancroid.  Moreover,  when  there  is  great  oedema,  there 
is  difficulty  in  accurately  gauging  the  flaps.  These  objections  are  not 
of  sufficient  weight  to  cause  circumcision  to  be  rejected  invariably ; 
indeed,  in  a  fair  proportion  of  cases,  when  every  antiseptic  precau- 
tion has  been  taken,  union  may  be  almost  as  prompt  as  when  non- 
chancroidal  lesions  are  subject  to  operation.  There  can,  however,  be 
no  certainty  that  the  circumcision  wound  will  remain  healthy. 

Paraphimosis. — When  paraphimosis  complicates  chancroid,  an 
effort  at  reduction  should  be  made  immediately,  unless  the  swelling 
is  so  great  that  there  is  obviously  no  chance  of  succeeding.  If,  as 
a  result  of  the  paraphimosis,  there  are  not  great  congestion  and 
oedema,  and  the  chancroid  is  not  obviously  extending,  it  may  be  suf- 
ficient to  treat  this  condition  in  accordance  with  ordinary  principles, 
— elevating  the  penis  and  keeping  it  swathed  in  cloths  wrapped  in 
evaporating  lotions.  If,  however,  the  oedema  is  rapidly  growing  more 
marked  and  the  ulcer  is  extending,  a  cutting  operation  should  be  prac- 
tised, the  paraphimosis  being  reduced.  Before  doing  this  it  is  well 
to  cauterize  the  chancroid  thoroughly,  and  after  the  reduction  to  sear 
the  operation  wound.  If  there  is  danger  of  converting  the  case  by 
reduction  to  one  of  inflammatory  phimosis,  the  foreskin  should  be 
split  along  its  dorsum,  as  advised  for  phimosis,  and  the  line  of  in- 
cision cauterized.  When  the  congestion  incident  to  phimosis  or  para- 
phimosis reaches  such  a  point  that  gangrene  is  threatened,  operative 
interference  is  imperative.  It  is  possible  to  treat  these  cases  under 
cocaine  anaesthesia,  but,  since  both  the  use  of  thi  knife  and  the  ap- 


56  GENITO-UEIlSrAEY   DISEASES   AND   SYPHILIS. 

plication  of  the  cautery  should  be  deliberate  and  thorough,  and  since 
the  results  of  hurried  or  partial  treatment  are  often  disastrous,  ether 
should  be  administered. 

Gangrene  and  Phagedena. — When  gangrene  develops,  the  first  in- 
dications are  to  relieve  constriction  or  pressure.  When  it  complicates 
a  phimosis  or  a  paraphimosis,  these  conditions  should  receive  prompt 
surgical  treatment.  The  patient  must  be  kept  in  bed.  Math  the  involved 
parts  elevated  and  v^rapped  in  hot  antiseptic  fomentations  frequently 
changed.  These  may  be  made  by  wringing  out  pads  formed  of  twenty 
or  thirty  layers  of  gauze  wet  in  bichloride  solution  1  to  4000  as  hot 
as  can  be  borne,  enveloping  the  gangrenous  regions  in  these  pads,  and 
covering  this  dressing  with  oiled  silk  to  prevent  evaporation.  These 
compresses  should  be  changed  every  fifteen  minutes.  Prolonged 
soaking  of  the  parts  in  hot  water  or  a  hot  mild  antiseptic  solution  is 
a  powerful  means  of  arresting  gangrene. 

If,  in  spite  of  treatment  by  heat,  the  gangrene  is  rapidly  extend- 
ing, the  parts  already  devitalized  should  be  clipped  away,  and  the 
ulcerated  and  raw  surfaces  should  receive  a  thorough  application  of 
the  actual  cautery,  or  of  nitric  acid,  the  field  of  operation  being  sub- 
sequently dressed  with  compresses  kept  wet  with  lead  water  and 
alcohol. 

In  all  these  cases  of  gangrene  the  constitutional  treatment  should 
receive  careful  attention  and  should  be  supporting  and  stimulating. 
Iron,  quinine,  and  nux  vomica  are  the  tonics  of  choice.  Potassio- 
ferric  tartrate  has  been  particularly  recommended.  Cod-liver  oil  will 
be  found  beneficial  in  perhaps  the  majority  of  cases. 

The  chronic  phagedenic  chancroid  and  the  serpiginous  sore  are  sO' 
invariably  associated  with  constitutional  dyscrasia  that  local  treatment 
alone  is  powerless  to  effect  a  cure.  Often  the  underlying  lesion  is 
syphilitic  in  nature  and  appropriate  specific  treatment  will  be  fol- 
lowed by  cure.  Frequently  it  is  tubercular  or  is  dependent  upon  vis- 
ceral lesions.  In  any  case  general  treatment  is  of  cardinal  importance. 
This  should  be  tonic  and  supporting  in  type.  Stimulants,  cod-liver 
oil,  the  hypophosphites,  and  arsenic  render  valuable  service.  Locally 
the  lesion  should  be  treated  in  accordance  with  the  condition  of  the 
granulating  surface :  thus,  applications  of  silver  nitrate  ten  per  cent., 
or  copper  sulphate  of  equal  strength,  followed  by  dusting  with  iodo- 
form, will  sometimes  be  followed  by  good  results.  Usually  these  and 
other  mild  methods  of  treatment  are  perfectly  futile.  In  such  cases  cau- 
terization of  the  entire  lesion,  followed  by  packing  with  iodoform  gauze 
and  the  apphcation  of  an  antiseptic  dressing,  may  accomplish  a  cure. 
In  some  instances  a  continuous  warm  bath,  lasting  for  days  or  even 


DISEASES   AND   INJURIES    OF   THE    PENIS.  57 

weeks,  has  caused  lesions  to  heal  which  had  resisted  every  other 
form  of  treatment.  This  bath  may  be  made  mildly  antiseptic  by  the 
addition  of  boric  acid  or  sublimate  ;  though  the  results  seem  to  be 
equally  favorable  when  water  alone  is  employed.  Occasionally  such 
cases  recover  when  complete  chginge  of  air  and  surroundings  is  m  ide, 
supplemented  by  ordinary  clean  dressings. 

Lymphangitis. — This  comparatively  rare  complication  of  chancroid 
is  treated  in  accordance  with  general  surgical  principles ;  that  is,  the 
chancroid  should  be  cleansed  and  drained,  the  penis  should  be  elevated 
and  swathed  in  cloths  wet  with  evaporating  lotions,  and  the  patient 
should  be  kept  quiet  on  ahght  diet,  and  should  have  his  bowels  thor- 
oughly opened.  Usually  resolution  takes  place.  Fluctuation  denotes 
that  pus  has  formed.  This  should  be  evacuated  by  a  small  puncture 
made  with  all  antiseptic  precautions,  and  the  cavity  washed  out  with 
peroxide,  followed  by  bichloride  1  to  2000,  and  sealed  up  with  an 
iodoform  gauze  collodion  dressing.  In  case  of  reaccumulation  the 
evacuation  and  washing  are  repeated.  If  inflammatory  phenomena 
become  pronounced,  the  abscess-cavity  should  be  freely  opened  and 
packed  with  iodoform  gauze.  These  abscesses  become  chancroidal 
only  because  of  inoculation  from  without. 

Lymphadenitis  or  Bubo. — This  complication  of  chancroid  will  usu- 
ally be  avoided  when  the  lesion  is  kept  thoroughly  clean  and  well 
drained  from  the  first  and  when  the  patient  remains  quiet.  Even  when 
the  glands  have  begun  to  swell,  as  evidenced  by  pain  and  tenderness 
in  the  groin  and  the  detection  of  a  distinct  lump,  further  enlargement 
can  often  be  prevented  by  rest  in  bed,  the  administration  of  a  saline 
purge,  and  the  apphcation  over  the  affected  region  of  heat  and  press- 
ure. This  is  best  applied  by  means  of  lint  wet  with  dilute  lead  water. 
Over  this  is  laid  the  ordinary  rubber  hot-water  bag,  fastened  in  place 
by  one  or  two  turns  of  a  spica,  the  patient  lying  on  his  back  in  bed. 
scrupulous  attention  being  paid  at  the  same  time  to  the  cleansing  of 
the  chancroid. 

When  this  treatment  by  rest  in  bed  and  application  of  heat  is  not 
practicable,  there  may  be  placed  over  the  sore  the  following  ointment : 

R   Ung.  hydrargyri, 
Ung.  iodi  comp., 
Ung.  belladonnse, 
Ung.  petrolei  carbolaf.,  aa  jii. 

Over  this  is  placed  ^  compress,  and  firm  pressure  is  made  on  the 
gland  by  means  of  a  spica  bandage. 

After  twenty-four  hours  of  this  treatment,  if  there  is  no  improve- 


58  GENITO- URINARY   DISEASES   AND   SYPHILIS. 

ment,  and  particularly  if  the  pain,  swelling,  and  inflammatory  phenom- 
ena are  more  marked,  time  and  suffering  will  be  saved  the  patient  by 
administering  ether  and  then  proceeding  at  once  to  excise  the  affected 
gland  or  glands,  since  it  is  almost  certain  in  these  cases  that  suppura- 
tion will  take  place.  The  excision  is  conducted  in  accordance  with 
the  principles  of  modern  surgery.  All  enlarged  glands  are  shelled  out, 
and  the  wound  is  thoroughly  cleaned,  and  is  closed  without  drainage. 
When  patients  object  to  this  radical  treatment, — and  this  will  be  in  the 
majority  of  cases, — an  effort  should  be  made  to  cause  resolution  by 
the  injection  of  antiseptic  solutions  into  the  substance  of  the  inflamed 
gland.  The  drug  most  employed  is  benzoate  of  mercury  in  one  per 
cent,  solution.  From  ten  to  fifteen  drops  of  this  are  driven  directly 
into  the  inflammatory  focus.  Antiseptic  compresses  and  a  pressure 
bandage  are  then  applied  over  the  affected  region.  This  is  followed 
by  increase  of  swelling  for  twenty-four  hours,  but  after  this  resolution 
usually  takes  place.  In  place  of  the  benzoate  of  mercury  a  three  per 
cent,  solution  of  carbohc  acid  may  be  employed  in  equal  quantity,  ten 
to  twenty  minims  being  injected  at  one  time. 

If  suppuration  occurs  in  spite  of  this  treatment,  or,  when  a  case 
first  comes  under  observation,  if  there  is  fluctuation,  the  abscess-sac 
should  be  punctured  under  antiseptic  precautions,  its  contents  squeezed 
out,  and  ten  per  cent,  iodoform  glycerin  emulsion  injected  under 
moderate  tension.  The  cavity  should  be  emptied  and  refilled  twice ; 
as  much  as  will  remain  of  the  third  filling  should  be  left  in,  and  over 
the  seat  of  abscess-formation  should  be  placed  a  large  absorbent  anti- 
septic dressing.  If,  following  this  operation,  there  is  reaccumulation 
of  fluid  in  the  abscess-cavity,  it  should  again  be  evacuated  by  punc- 
ture and  injected  with  the  iodoform  emulsion.  If  more  than  two 
punctures  are  required,  the  cavities  should  be  freely  incised,  gently 
curetted,  packed  with  sterile  iodoform  gauze,  and  dressed  antiseptically. 

If  when  the  case  comes  under  observation  there  is  a  large  abscess 
with  the  overlying  skin  livid  and  devitalized,  or  already  ulcerated 
through,  the  cavity  should  be  opened  by  a  free  incision  parallel  to 
Poupart's  ligament.  Careful  search  should  be  made  for  glands  begin- 
ning to  soften  but  not  yet  completely  broken  down,  which  should  be 
removed  either  by  means  of  blunt  dissection  with  the  finger,  or  by 
careful  cutting  with  the  knife.  The  whole  wound  cavity  should  be 
thoroughly  curetted,  and  should  be  packed  with  sterile  iodoform  gauze. 
Any  sinuses  which  may  form  must  be  followed  to  their  end,  being 
fireely  slit  open  to  the  surface.  This  operation  sometimes  results  in 
an  enormous  wound,  but  no  hesitation  should  be  felt  in  making  it, 
since  otherwise  ultimate  cure  is  uncertain. 


DISEASES   AND    [NJURIES    OF    THE    PENIS.  59 

When  that  form  of  inflammation  is  encountered  which  is  some- 
times seen  in  tubercular  cases, — that  is,  when  gland  after  gland  en- 
larges and  slowly  breaks  down,  its  capsule  becoming  firmly  adherent 
to  the  surrounding  parts  and  the  whole  forming  a  large  lobulated 
tumor, — removal  by  careful  dicsection  is  the  only  means  of  treatment 
which  will  be  followed  by  cure.  In  these  cases  the  glands  sometimes 
contract  adhesions  to  the  femoral  vein,  and  a  number  of  deaths  have 
been  recorded  from  the  wounding  of  this  vessel  in  the  course  of  an 
operation.  Following  the  dissection  the  wound  is  packed  with  iodo- 
form gauze. 

When  the  bubo  has  ruptured  before  it  has  come  under  observa- 
tion, and  when  it  is  infected  with  the  ordinary  pyogenic  microbes,  in 
addition  to  free  incision  and  curetting  it  is  well  to  paint  the  whole 
raw  surface  with  a  solution  of  zinc  chloride,  sixty  grains  to  the  ounce, 
subsequently  packing  with  iodoform  and  dressing  the  wound  as  before 
described. 

When  a  bubo  becomes  chancroidal  in  type,  the  resultant  sore 
should  be  treated  in  accordance  with  the  principles  governing  the  treat- 
ment of  chancroid.  Thorough  cauterization  will  usually  be  followed 
by  prompt  cure.  If  cauterants  cannot  be  employed,  applications  of 
the  ordinary  antiseptics  are  often  efficacious.  These  chancroidal 
buboes  are  of  course  subject  to  the  same  inflammatory  complications 
as  are  chancroids  of  the  penis. 

The  after-treatment  of  buboes  which  have  been  operated  on  is 
comparatively  simple.  Rest  in  bed  is  advisable  for  at  least  from 
five  to  seven  days,  since  thus  the  parts  wifl  be  kept  quiet.  A  spica 
of  the  groin  holds  the  dressing  in  place.  This  is  to  be  changed  in 
accordance  with  the  strictest  antiseptic  principles,  since  it  is  possible 
at  any  time  to  have  the  ulcerating  surface  inoculated  with  the  chan- 
croidal virus.  In  some  instances  healing  goes  on  more  rapidly  when 
the  patient  is  allowed  to  be  up  and  about  than  when  he  is  kept  in  bed. 
If,  however,  walking  or  sitting  in  the  erect  posture  retards  healing,  the 
patient  should  be  kept  in  bed  until  convalescence  is  established. 

The  treatment  of  chancroidal  buboes  may  be  summarized  as  fol- 
lows, 1.  Buboes  are  to  be  avoided  by  thorough  frequent  cleansing  of 
the  chancroids  and  by  rest  upon  the  part  of  the  patient.  2.  They  may 
be  aborted  in  their  earliest  stages  by  active  purgation,  by  rest  in  bed, 
and  by  the  application  of  heat  and  pressure.  If  in  twenty-four  hours 
abortive  treatment  is  not  followed  by  improvement,  no  further  effort 
should  be  made  in  this  direction.  3.  If  the  bubo  is  steadily  progressing 
in  spite  of  appropriate  treatment,  excision  before  softening  has  occuiTed 
offers  the  quickest  method  of  cure.    4.  When  this  is  not  practicable,  in- 


60  GENITO-UKINARY    DISEASES   AND   SYPHILIS. 

jections  of  antiseptics  into  the  substance  of  the  diseased  glands,  fol- 
lowed by  pressure  and  rest,  will  often  bring  about  resolution.  5.  When 
softening  has  occurred,  but  the  skin  is  not  yet  involved,  evacuation 
of  the  contents  of  the  abscess  through  a  small  puncture,  followed  by 
iodoform  injection  or  antiseptic  irrigation  and  the  application  of  a 
pressure  bandage,  will  favor  resolution.  6.  If  after  this  treatment 
once  repeated  the  abscess-cavity  again  fills,  or  if  the  abscess  is  large 
and  the  skin  is  already  partly  devitalized,  the  abscess  should  be  opened 
by  free  incision  parallel  with  Poupart's  ligament,  all  enlarged  glands 
should  be  shelled  out  or  excised,  all  sinuses  should  be  followed  to  their 
extreme  limit  and  opened  freely,  and  the  ulcerating  wound  should 
be  packed  with  iodoform  gauze.  7.  This  same  treatment  should  be 
applied  to  buboes  which  have  already  opened  spontaneously,  and 
should  be  supplemented  by  the  apphcation  of  zinc  chloride,  sixty 
grains  to  the  ounce,  to  the  curetted  surfaces.  8.  The  tubercular  type 
of  bubo  requires  excision  of  all  the  enlarged  glands.  9.  All  operations 
on  chancroidal  buboes  should  be  conducted  with  scrupulous  regard 
to  the  principles  of  antisepsis. 

Chancre  of  the  penis  and  the  ulcerative  lesions  of  the  secondary 
and  tertiary  stages  of  the  disease  are  discussed  under  Syphilis. 

TUMORS   OF   THE   PENIS. 

Tumors  of  the  penis  may  be  cystic  or  solid,  benign  or  malignant. 

Under  the  benign  tumors  are  included  the  cysts,  sebaceous,  blood,, 
and  mucous,  papilloma,  horny  growths,  lymphangioma,  fibroma,  and 
adenoma.     Except  papilloma,  these  lesions  are  rare. 

The  malignant  tumors  include  carcinoma,  sarcoma,  and  epithe- 
lioma. The  latter  is  by  far  the  commonest  form  of  cancerous  growth. 
Carcinoma  and  sarcoma  are  sometimes  observed  in  infants. 

Cysts,  fibroma,  angioma,  etc.,  are  so  rarely  observed,  and 
when  seen  coincide  so  completely  with  similar  growths  of  other  parts 
of  the  body,  that  they  require  no  detailed  mention.  Sebaceous  cysts 
are  occasionally  seen  in  the  prepuce.  Cysts  from  distention  of 
Tyson's  glands  may  be  multiple,  and  sometimes  reach  large  size. 
Angiomata  have  caused  troublesome  bladder  reflexes. 

The  treatment  is  the  same  as  that  appropriate  to  like  conditions 
in  other  parts  of  the  body, — i.e.,  removal  when  they  are  increasing  in 
size  or  cause  pain  or  interfere  with  function. 

Lymphangioma,  or  elephantiasis,  rarely  involves  the  penis 
alone  ;  usually  the  scrotum  is  implicated.  When  secondary  to  inflam- 
mation or  removal  of  the  inguinal  glands  it  may  be  self-limited  and 
transitory.     Operation  may  be  required.     (See  page  624.)    The  filaria 


DISEASES    AND   INJURIES   OF    THE    PENIS. 


61 


Fig.  28. 


may  or  may  not  be  found.  The  diagnosis  is  nearly  always  rendered 
easy  by  a  history  of  preceding  inguinal  adenitis  or  by  the  associated 
thickening  of  the  skin  of  the  scrotum  and  lower  extremities.  When 
the  foreskin  is  primarily  attacked,  at  least  in  the  early  stages,  it  may 
be  difficult,  and  at  times  even  impossible,  to  decide  whether  the  over- 
growth is  due  to  infiltration  consequent  upon  a  chronic  balanoposthitis, 
or  to  elephantiasis.  The  steady  progress  of  the  infiltration,  in  spite  of 
local  cleanliness,  would  in  a  short  time  lead  to  a  correct  diagnosis. 

Verrucse  or  Papillomata. — Venereal  warts  appear  as  small  or 
large,   discrete    or    confluent,    moist   or   dry   papillary    overgrowths, 
usually  springing  from  the  coronary  sulcus,  the  posterior  border  of 
the  glans  penis,  the  inner  surface  and 
margin  of  the  prepuce,  the  region  of 
the  fraenum,  and  the  orifice  of  the  ure- 
thra.    (Fig.  28.) 

Pathologically  these  outgrowths  are 
found  to  be  due  to  hypertrophy  of  the 
papillary  and  mucous  layers  of  the  skin. 
At  the  same  time  there  is  a  correspond- 
ing development  of  blood-vessels.  On 
the  mucous  surfaces  they  are  moist, 
from  maceration  of  the  epithelial  cov- 
ering ;  on  the  skin  surfaces,  as  the  penis, 
scrotum,  or  thigh,  they  are  generally  dry. 

The  cause  of  venereal  warts  can 
usually  be  traced  to  irritation  incident 
to  prolonged  contact  with  inflammatory 
discharges.  Thus,  in  the  uncleanly,  in 
those  suffering  from  gonorrhoea,  herpes, 
chancroid,  or  balanoposthitis,  papillary 
outgrowths  are  by  no  means  uncommon. 
The  most  important  predisposing  cause  is  a  redundant  or  phimotic 
foreskin.  In  addition  there  seems  to  be  in  certain  persons  a  consti- 
tutional predisposition  towards  papillary  outgrowths.  Proof  as  to  the 
contagious  nature  of  discharges  from  venereal  warts  is  still  wanting, 
though  there  are  many  recorded  cases  of  condylomata  developing 
apparently  as  the  result  of  contagion. 

Symptoms. — Condylomata  are  found  most  often  in  men  between 
the  fifteenth  and  the  twenty-fifth  year,  and  in  those  who  give  a  history 
of  inflammation  about  the  genitalia,  either  from  disease  or  from  redun- 
dant foreskin.  They  appear  as  markedly  vascular  outgrowths  from 
either  the  skin  or  the  mucous  menibrane.     Sometimes  they  project 


Venereal  warts. 


62  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

like  one  or  more  threads,  or  may  form  discrete,  small-sized,  tuberous 
excrescences,  or  by  confluence  may  produce  an  outgrowth  resembling 
a  raspberry  or  a  cauliflower.  The  confluent  warts  often  assume  the 
shape  into  which  they  are  moulded  by  the  pressure  of  the  surround- 
ing parts  ;  thus,  under  the  prepuce,  pressed  beneath  the  foreskin  and 
the  glans,  they  may  be  flat  and  broad  like  a  cock's  comb. 

Diagnosis. — Venereal  warts  may  be  confounded  with  the  mucous 
patch  or  condyloma  lata,  and  with  epithelioma. 

The  condyloma  lata  or  mucous  patch  rarely  appears  as  an  isolated 
lesion  of  syphilis ;  the  concomitant  signs  of  the  disease  and  a  history 
of  the  case  usually  indicate  the  nature  of  the  affection,  though  it  must 
not  be  forgotten  that  syphilis  may  excite  true  papillary  overgrowth 
almost  identical  in  appearance  with  the  overgrowth  of  condyloma 
acuminata. 

Epithelioma  usually  occurs  after  middle  life.  It  ulcerates,  grows 
rapidly,  involves  the  surrounding  tissues  in  a  dense  infiltrate,  and  is 
accompanied  by  a  characteristic  induration  of  the  inguinal  glands. 

A  wart  found  upon  the  sexual  organs  of  an  old  person,  even  if 
characteristic  in  appearance,  should  always  excite  suspicion,  since  this 
benign  neoplasm  is  comparatively  rare  after  middle  life,  while  malig- 
nant growths  are  by  no  means  uncommon,  and  in  their  early  period 
closely  resemble  the  venereal  wart. 

At  the  time  the  differential  diagnosis  is  most  important,  i.e.,  in  the 
beginning,  it  is  most  difficult.  It  should  be  remembered  that  even  at 
this  period  of  the  disease  the  malignant  growth  infiltrates  the  tissues 
from  which  it  springs. 

Only  by  means  of  microscopic  examination  of  sections  from  the 
outgTowth  can  a  positive  opinion  be  given,  since  clinical  experience 
shows  that  the  benign  neoplasm  is  at  times  transformed  into  a  malig- 
nant growth. 

Prognosis. — Venereal  warts,  if  kept  clean,  and  protected  from 
mechanical  irritation,  spontaneously  disappear,  though  predictions  as 
to  when  this  result  will  occur  can  never  be  made  with  safety.  If 
utterly  neglected,  they  ulcerate  and  suppurate,  and  may  often  be 
complicated  by  inflammatory  buboes  or  by  sloughing  and  gangrene. 
Exceptionally  they  form  the  starting  point  of  cancer. 

Trea/me?i^.— Complete  removal  of  the  papilloma  constitutes  the 
only  reliable  treatment.  Where  the  outgrowths  are  discrete  and 
small,  each  is  seized  in  a  pair  of  rat-tooth  forceps,  drawn  upward, 
and  removed,  together  with  the  tissues  of  its  base,  by  a  snip  of  the 
scissors  after  having  had  injected  beneath  its  base  a  drop  of  a  one  per 
cent,  solution  of  eucaine.     If  the  warts  spring  from  the  glans,  the 


DISEASES   AND    INJURIES   OF   THE    PENIS.  63 

little  bleeding  points  left  by  this  cutting  are  touched  with  pure  car- 
bolic acid,  and  the  dressing  is  completed  by  dusting  with  iodoform  or 
other  powder,  and,  if  necessary,  applying  a  clean  narrow  gauze  press- 
ure bandage.  The  wound  left  by  snipping  warts  from  the  prepuce  is 
at  once  closed  by  suture  without  cauterization.  When  the  neoplasm 
has  a  large  base,  the  whole  outgrowth  may  be  shaved  off  level  with 
the  surrounding  surface  by  means  of  a  sharp,  flat  knife.  The  wound 
left  by  this  incision  should  be  thoroughly  curetted,  and  then  should  be 
cauterized  with  carbolic  or  nitric  acid  and  dressed  with  iodoform  or 
with  a  powder  made  of  calomel  and  zinc  oxide,  equal  parts  of  each. 
General  ansesthesia  is  required  for  this  operation.  Only  spouting  ves- 
sels should  be  ligated,  the  free  primary  oozing  being  readily  controlled 
by  the  appKcation  of  adrenalin  chloride  solution  (1  to  1000). 

At  the  time  this  operation  is  performed  an  effort  should  be  made 
to  remove  the  exciting  cause  of  the  lesion.  Thus,  phimotic  patients 
should  be  circumcised,  urethral  discharges  should  be  prevented  from 
coming  in  contact  with  the  external  parts,  etc. 

When  operation  is  refused,  warts  may  be  removed  by  nitric  acid. 
The  surrounding  surfaces  should  be  protected  by  the  application  of 
cosmoline  ;  the  acid  is  well  rubbed  into  the  wart  and  a  boric  ointment 
dressing  is  applied.  The  application  is  repeated  every  second  or  third 
day  until  the  papillary  layer  of  the  skin  is  destroyed  at  the  point  of 
outgrowth. 

Chromic  acid  is  an  excellent  application,  but  is  open  to  the  objec- 
tion that  occasionally  it  gives  rise  to  general  toxic  symptoms.  Fatal 
cases  have  been  reported.  It  is  usually  employed  either  pure  or  in 
a  ten  per  cent,  solution,  brushed  over  the  outgrowth  once  daily. 

Certain  non-cauterant  remedies  are  advised,  and  at  times  give 
good  results,  possibly  because  of  the  spontaneous  tendency  towards 
healing  exhibited  by  the  condylomata.  Among  these  may  be  men- 
tioned the  following : 

R   Acidl  salicylici,   31; 
Acidi  acetici,  f^i. 
M.      S. — Apply  with  a  brush  once  daily. 

The  effect  of  irritants  not  strong  enough  to  act  as  cauterants  is  to 
stimulate  the  papillary  outgrowths. 

Horny  Growths  of  the  Penis. — In  the  few  reported  cases  of 
this  affection  the  growth  has  sprung  from  the  surface  of  the  glans 
penis  of  old  men.  It  is  an  extremely  rare  manifestation  of  perverted 
epidermic  hypertrophy.  It  is  easily  recognized,  and  its  main  patho- 
logical importance  lies  in  the  fact  that  it  is  at  times  the  forerunner  of 
cancer.     The  appropriate  treatment  is  the  thorough  removal  of  the 


64 


GEXITO-UEINARY   DISEASES   AND   SYPHILIS. 


horn,  together  with  the  base  from  which  it  grows.  When  the  patient 
is  advanced  in  years  and  there  is  no  indication  of  epitheUomatous 
degeneration,  surgical  operation  is  not  indicated. 

Malignant  Disease. — With  the  exception  of  epithehoma,  malig- 
nant disease  of  the  penis  is  extremely  rare. 

A  few  cases  of  medullary  cancer  have  been  described.  These  de- 
velop  about  the  period  of  puberty,  and  are  apt  to  be  consequent  on 
trauma.  They  form  rapidly  growing,  lobulated,  painful  tumors.  The 
lobules  may  be  so  soft  as  to  suggest  the  formation  of  a  cyst.  There 
are  usually  the  phenomena  of  subacute  inflammation,  and  the  lym- 
phatic glands  of  the  groin  are  quickly  involved.     Amputation  carried 

wide  of    the    disease    is 
^'^'-  -^-  the    only  treatment,  and 

even  if  this  procedure 
be  adopted  early,  the 
ultimate  outlook  is  ex- 
tremely unfavorable. 

Epithelioma  commonly 
appears    on    either    the 
■  glans  or  the  prepuce.     It 

may  assume  the  super- 
ficial or  the  infiltrating 
form.  (Fig.  29.)  It 
usually  develops  after 
middle  age,  and  some- 
times grows  from  the  seat 
of  a  former  chancre. 

Symptoms.  —  Epitheli- 
oma generally  appears 
first  in  the  form  of 
a  wart,  which  becomes 
excoriated,  ulcerated,  and 
shortly  indurated.  The 
disease,  beginning  as  a 
small  ulcerative  vegeta- 
tion, gradually  extends 
until  a  large  portion  of  the  prepuce  and  glans  is  involved.  (Fig.  30.) 
The  ulceration  has  a  hard  base  and  is  irregularly  excavated.  Together 
with  the  deep  ulcers  there  are  often  cauliflower-like  outgrowths.  (Fig. 
31.)  The  surrounding  skin  is  infiltrated,  (Edematous,  nodular,  ele- 
vated, and  purplish  in  color.  The  glans  is  greatly  swollen,  irregular 
in  outline,  and  lobulated. 


Epithelioma.    (Demarquay.) 


P^G.  30. 


Epithelioma,  ulcerating  form. 
Fig.  31. 


Epithelioma,  vegetating  form. 


DISEASES   AND   INJURIES  OF   THE    PENIS. 


65 


As  the  disease  extends  backward  the  cavernous  bodies  become 
indurated  and  the  overlying  skin,  at  first  slightly  adherent,  is  involved 


^ 


Epithelioma  with  glandular  involvement. 

in  the  disease.  Finally  the  lymphatic  glands  of  the  groin  become 
infiltrated  and  ulcerated,  and  discharge  fetid,  blood-stained  pus. 
(Fig.  32.) 

Etiology. — The    pres-  Fig.  33. 

ence  of  a  redundant  or 
phimotic  foreskin,  accu- 
mulations   of     smegma, 

subpreputial  calculi,       i^st  ■  \ 

chronic  balanoposthitis, 
specific  or  non-specific 
ulcerations,  indeed,  any 
source  of  local  irritation, 
may  act  as  a  predisposing 
cause  for  the  develop- 
ment of  epithelioma. 

Diagnosis. — This  is 
difficult  only  in  the  early 
stages  of  the  disease. 

When  without  ob- 
vious    cause     a     warty 

growth  develops  on  the  glans  or  the  foreskin  in  a  person  past  middle 
life,  this  lesion  should  be  carefully  watched.  Induration  about  the 
base  (Fig.  33)  or  ulceration  of  the  excrescence  would  justify  the 
diagnosis  of  epithehoma,  and  would  indicate  a  prompt  removal. 

5 


.y 


Cross-section  showing  infiltration  of  an  epithelioma. 
(Demarquay.) 


66  GENITO-UKINARY    DISEASES   AND   SYPHlLlb. 

Prognosis. — The  prognosis  of  epithelioma  is  grave  unless  operation 
is  undertaken  in  its  very  earliest  stages.  The  course  of  the  affection 
varies  greatly  in  different  cases.  Some  patients  perish  in  two  months, 
others  survive  for  many  years.  When  the  inguinal  glands  are  involved 
there  is  but  slight  chance  of  ultimate  recovery. 

Treatment. — The  only  treatment  to  be  considered  in  these  cases 
is  entire  removal  of  the  diseased  part.  When  the  disease  has  not 
developed  further  than  slight  ulceration  of  an  indurated  papule,  total 
excision  of  the  involved  area,  with  subsequent  cauterization  of  the 
excision  wound  by  means  of  caustic  potash,  may  suffice. 

When  epithelioma  is  fairly  developed,  amputation  carried  wide  of 
the  disease  is  the  only  resource.  The  inguinal  lymphatic  glands  should 
be  removed  at  the  same  time,  even  though  not  enlarged. 

Syphilis  of  the  Penis  may  be  mistaken  for  epithelioma,  but  may 
be  recognized  by  the  characteristics  described  under  this  sLibject. 

Partial  Amputation  of  the  Penis. — This  operation  is  indicated 
when  the  ulceration  or  infiltration  lies  an  inch  or  more  in  front  of  the 
peno-scrotal  junction.  The  ulcerating  mass  having  been  cauterized 
with  pure  carbolic  acid  and  occluded  by  a  dressing  wet  in  1  to  1000 
corrosive  chloride,  and  the  inguinal  regions  having  been  thoroughly 
cleansed  as  for  any  surgical  operation,  an  incision  is  carried  from  the 
middle  of  Poupart's  hgament  to  the  dorsum  of  the  penis,  thence  down 
the  middle  of  this  organ  to  the  seat  of  amputation.  The  superficial 
layer  of  fat  containing  the  glands  is  then  dissected  up  from  each 
inguinal  region  and  is  stripped  inward,  including  the  lymphatic  vessels 
of  the  penis.  This  mass  of  tissue,  made  up  of  two  wings,  is  carried 
downward  and  the  Y-shaped  incision  is  closed  by  suture.  Two  inches 
or  more  behind  the  epithelioma  a  stout  acupressure  needle  is  thrust 
through  the  corpora  cavernosa  from  side  to  side,  and  behind  this  a 
medium-sized  drainage-tube  is  wound  two  or  three  times  around  the 
penis  and  kept  in  place  by  catch  forceps  or  by  knotting.  By  a  circular 
sweep  of  the  knife  the  skin  of  the  penis  is  divided  at  the  proposed  seat 
of  amputation,  which  should  be  at  least  one  inch  behind  the  farthest 
backward  extension  of  the  malignant  infiltration.  Half  an  inch  in  front 
of  this  the  spongy  body  of  the  urethra  is  cut  across  and  dissected 
back  to  the  level  of  the  skin  incision.  The  corpora  cavernosa  arfe 
then  cut  through  on  a  level  with  the  first  incision,  the  rubber  ligature 
is  removed,  the  bleeding  vessels  are  secured  by  means  of  fine-pointed 
haemostatic  forceps  and  by  catgut  ligatures,  and  the  acupressure  pin  is 
taken  out.  Sutures  are  then  passed  drawing  together  the  cut  edges 
of  the  fibrous  sheaths  of  the  cavernous  bodies,  thus  completely  cover- 
ing in  the  vascular  erectile  tissue,  and  both  protecting  it  from  subse- 


DISEASES   AND   INJURIES   OF    THE    PENIS.  67 

quent  infiltration  and  infection  by  the  urine  and  immediately  checking 
oozing.  The  urethra  is  split  on  its  floor  back  to  the  level  of  the  sur- 
face of  the  divided  cavernous  bodies.  The  borders  of  this  incision, 
together  with  the  divided  urethral  end,  are  sutured  to  the  skin.  The 
latter  is  then  stitched  so  as  to  cover  in  the  cavernous  bodies.  The 
line  of  suture  is  dusted  with  iodoform  and  is  dressed  with  iodoform 
gauze.  The  dressing  is  held  in  place  by  a  T-bandage.  Continuous 
catheterization  may  be  employed ;  it  is  better,  however,  to  let  the 
patient  micturate  when  desire  prompts,  removing  the  dressing  to  allow 
of  this  and  irrigating  the  wound  immediately  afterwards  with  corrosive 
chloride  solution  1  to  4000. 

Recurrence  in  the  stump  after  partial  amputation  is  rare,  death 
usually  resulting  from  lymphatic  involvement.  During  a  partial  ampu- 
tation, with  the  help  of  a  freezing  microtome,  the  cross-section  should 
be  carefully  examined  for  evidences  of  malignant  infiltration,  which  if 
found  would  indicate  a  more  complete  removal.  The  stump  following 
the  partial  operation  enables  the  patient  to  urinate  normally  and  at 
times  to  satisfactorily  accomplish  the  sexual  act. 

Amputation  of  the  Entire  Penis. — This  procedure  is  indicated 
when  the  disease  is  so  far  advanced  that  partial  excision  can  no 
longer  be  considered.     Treves  describes  the  operation  as  follows : 

The  patient  is  placed  in  the  lithotomy  position,  and  the  skin  of  the 
scrotum  is  incised  along  the  whole  length  of  the  raphe.  With  the 
finger  and  the  handle  of  the  scalpel  the  halves  of  the  scrotum  are 
separated  down  to  the  corpus  spongiosum.  A  full-sized  metal  cath- 
eter is  passed  as  far  as  the  triangular  ligament,  and  a  knife  is  inserted 
transversely  between  the  corpora  cavernosa  and  the  corpus  spongio- 
sum. The  catheter  is  withdrawn,  the  urethra  is  cut  across,  and  its 
deep  end  is  detached  from  the  penis  back  to  the  triangular  ligament. 
An  incision  is  made  around  the  root  of  the  penis  continuous  with 
that  in  the  median  line.  The  suspensory  ligament  is  divided  and  the 
penis  is  separated,  except  at  the  attachment  to  the  crus.  The  knife 
is  then  laid  aside,  and  with  a  stout  periosteal  elevator  or  rugine  each 
crus  is  detached  from  the  pubic  arch.  The  two  arteries  of  the  cor- 
pora cavernosa  and  the  two  dorsal  arteries  require  ligature.  The 
urethra  and  corpus  spongiosum  are  split  up  for  about  half  an  inch, 
and  the  edges  of  the  cut  are  stitched  to  the  back  part  of  the  incision 
in  the  scrotum.  The  scrotal  incision  is  closed  by  sutures,  and  if 
drainage  is  used  the  tube  is  so  placed  in  the  deep  part  of  the  wound 
that  its  end  can  be  brought  out  in  front  and  behind.  A  catheter  is 
usually  retained  in  the  urethra. 


CHAPTER   II. 

INJURIES    AND    DISEASES    OF    THE    URETHRA. 

The  Anatomy  of  the  Urethra. — The  urethra,  serving  the 
double  purpose  of  a  carrier  for  the  urine  and  for  the  semen,  is  a 
tubular  passage  about  eight  inches  in  length,  of  somewhat  changing 
calibre  in  various  parts  of  its  course.  Originating  from  the  bladder, 
it  passes  through  the  upper  part  of  the  central  portion  of  the  prostate 
gland,  pierces  the  anterior  and  posterior  layers  of  the  triangular  liga- 
ment about  one  inch  below  the  lower  border  of  the  pubic  symphysis, 
and  then,  surrounded  by  the  corpus  spongiosum,  passes  on  to  the 
meatus. 

The  prostatic  portion  of  the  urethra  is  about  an  inch  and  a  quarter 
long,  and  is  the  widest  and  most  dilatable  part  of  the  canal ;  the 
membranous  portion  is  about  three-quarters  of  an  inch  long,  and  is 
the  narrowest,  least  dilatable  part  of  the  urethra,  except  the  meatus. 
The  spongy  or  penile  portion  of  the  canal  is  about  six  inches  in 
length. 

The  meatus  is  the  narrowest  part  of  the  urethra.  Immediately 
behind  this  opening  the  passage  widens  somewhat,  forming  the  fossa 
navicularis.  Passing  backward,  the  urethra  becomes  slightly  nar- 
rower, and,  exhibiting  a  nearly  uniform  diameter,  traverses  the 
spongy  body  till  it  reaches  the  bulb,  or  posterior  portion  of  this  body, 
where  it  again  dilates.  This  dilatation  narrows  abruptly  at  the  an- 
terior layer  of  the  triangular  ligament,  the  membranous  urethra  being 
of  small  but  uniform  calibre.  After  passing  through  the  posterior 
layer  of  the  triangular  ligament  the  urethra  again  widens  out,  reaching 
its  greatest  diameter  at  the  position  of  the  caput  gallinaginis.  Be- 
fore passing  into  the  bladder  there  is  a  slight  narrowing,  noticeable 
only  when  the  latter  viscus  is  empty. 

There  are,  then,  three  regions  of  physiological  dilatation.  These 
are  located  in  the  prostate  gland,  at  the  bulb,  and  behind  the  meatus. 

The  natural  positions  of  physiological  narrowing  are  at  the  meatus 
and  the  membranous  portion  of  the  canal. 

The  epithelial  lining  of  the  mucous  membrane  of  the  urethra  is 
flat  and  laminated  near  the  meatus ;  in  other  portions  of  the  tube  it 
is  coluinnar. 

68 


INJUEIES   AND   DISEASES   OF   THE  UKETHRA.  59 

The  mucous  membrane  is  continuous  with  the  bladder  internally 
and  with  the  integument  of  the  glans  penis  externally.  It  is  pro- 
longed into  the  ducts  of  all  the  glands  which  open  into  the  urethra. 

The  submucous  tissue  is  made  up  of  fibrous  and  elastic  tissue, 
together  with  unstriped  muscular  fibres.  These  latter  are  arranged 
in  two  layers,  one  passing  longitudinally,  the  other  circularly.  This 
muscular  layer  is  most  markod  in  the  prostatic  and  membranous  por- 
tions of  the  urethra  ;  passing  forward,  it  becomes  thinner,  till  in  the 
anterior  part  of  the  spongy  urethra  it  is  replaced  in  a  great  measure 
by  fibrous  tissue. 

On  the  mucous  membrane  of  the  urethra  may  be  seon  the  open- 
ings of  many  glands  and  follicles.  These  are  situated  in  the  sub- 
mucous tissue.  The  glands,  called  the  glands  of  Littre,  vary  greatly 
in  size,  and  are  most  abundant  in  the  spongy  portion  of  the  canal  and 
about  the  meatus.  Their  orifices  are  directed  forward.  The  largest 
of  the  follicles,  called  the  lacuna  magna,  is  situated  in  the  upper  wall 
of  the  fossa  navicularis,  and  is  one  and  one-half  inches  from  the 
meatus. 

The  spongy  portion  of  the  urethra,  so  named  because  it  is  sur- 
rounded by  the  erectile  tissue  of  the  corpus  spongiosum,  extends  from 
the  meatus  to  the  anterior  layer  of  the  triangular  ligament.  It  is  fur- 
ther subdivided  into  a  pendulous  and  a  bulbous  portion.  The  pendu- 
lous portion  extends  from  the  meatus  to  the  dilatation  enclosed  by 
the  bulb  (about  four  and  one-half  inches  in  length).  The  bulbous 
portion  or  dilatation  (about  an  inch  to  an  inch  and  a  half  long)  is 
abundantly  supplied  with  mucous  glands  and  follicles  ;  into  it  also 
pass  the  ducts  of  Cowper's  glands.  In  direction  the  spongy  urethra 
first  passes  upward,  then  curves  downward. 

The  membranous  portion  of  the  urethra,  beginning  at  the  prostate 
gland  and  ending  at  the  bulb,  is  separated  from  the  pubic  symphysis 
by  muscular  fibre  and  by  the  dorsal  vessels  and  nerves  of  the  penis ; 
below  it  he  Cowper's  glands.  Its  upper  surface  is  concave,  and  is 
about  one-quarter  of  an  inch  longer  than  the  lower  surface.  The 
perineum  separates  the  lower  surface  of  the  membranous  urethra 
from  the  rectum.  In  this  portion  of  the  urethra  the  erectile  tissue  is 
but  slightly  developed.  In  place  of  this  there  is  a  compKcated  invest- 
ment of  muscular  fibres.  First  there  is  a  layer  of  unstriped  fibres 
passing  circularly  and  longitudinally.  External  to  this  there  is  an 
investment  of  voluntary  muscular  fibres  completely  surrounding  the 
urethra.     This  muscular  sheath  is  named  the  compressor  urethrae. 

The  prostatic  urethra  is  spindle-shaped, — that  is,  it  is  widest  at  its 
middle.    On  the  floor  of  the  canal  the  mucous  membrane  is  projected 


70  GEXITO-UKIXAKY   DISEASES   AXD   SYPHILIS. 

in  the  form  of  a  longitudinal  ridge,  called  the  yerumontanum,  or  caput 
gallinaginis.  On  each  side  of  this  ridge  lies  a  depression,  called  the 
prostatic  sinus,  into  which  .open  the  orifices  of  the  prostatic  ducts. 
Immediately  in  front  of  the  yerumontanum  is  the  sinus  pocularis,  a 
blind  pouch  running  upward  and  backward  beneath  the  middle  por- 
tion of  the  prostate  gland.  At  or  just  within  the  margin  of  the  sinus 
pocularis  are  the  slit-like  openings  of  the  ejaculatory  ducts. 

At  the  point  where  the  prostatic  urethra  enters  the  bladder  it  is 
surrounded  by  a  muscle  made  up  of  unstriped  fibres,  called  the  in- 
ternal vesical  sphincter ;  anterior  to  this  .a  double  layer  of  unstriped 
muscular  fibres  and  the  glandular  structure  of  the  prostate  surround 
the  urethra.  At  the  apex  of  the  prostate  there  is  a  sphincter  made 
up  of  both  yoluntary  and  'nyoluntary  muscular  fibres ;  this  is  called 
the  external  vesical  sphincter. 

The  discharge  ^f  urine  from  the  bladder  is  prevented  by  the  tonic 
contraction  of  the  muscular  apparatus  of  the  membranous  and  the 
prostatic  urethra.  As  the  bladder  becomes  distended,  the  internal 
vesical  sphincter  yields,  and  the  urine  enters  the  posterior  part  of  the 
prostatic  urethra,  causing  a  desire  to  urinate,  which  is  resisted  by  the 
action  of  the  voluntary  fibres  of  the  external  vesical  sphincter  and 
the  compressor  urethras.  On  passing  a  catheter  when  the  bladder  is 
full,  the  urethra  seems  about  an  inch  shorter  than  it  does  imme- 
diately after  micturition;  this  is  owing  to  the  participation  of  the  pos- 
terior portion  of  the  prostatic  urethra  in  the  retentive  function  of  the 
bladder. 

The  compressor  urethrae  muscle  is  readily  excited  to  reflex  spasm. 
Ordinarily,  on  the  passage  of  instruments,  a  moderate  degree  of  resist- 
ance can  be  detected,  due  to  the  contraction  of  this  muscle.  In  irri- 
table conditions  of  the  mucous  membrane  there  may  be  excited  a 
spasm  so  violent  that  it  will  be  impossible  to  introduce  a  soft  instru- 
ment. Such  a  spasm  may  also  be  excited  by  irritation  of  the  prostatic 
urethra,  either  from  distention  of  the  bladder  or  from  any  other  cause. 
Thus,  it  is  often  found  extremely  difficult  to  evacuate  the  bladder  when 
the  desire  to  urinate  has  been  resisted  for  many  hours,  and  acute 
inflammation  of  the  posterior  urethra  not  infrequently  requires  the 
use  of  catheters  to  overcome  the  tight  muscular  contraction  of  the 
compressor  urethrae  which  prevents  micturition.  Not  only  the  intro- 
duction of  sounds,  but  even  the  injection  of  bland  liquids,  will  cause 
contraction  of  the  compressor  urethrse  muscle,  and  hence  prevent 
such  injection  from  reaching  the  membranous  or  the  prostatic  urethra. 
Any  inflammation  in  these  portions  of  the  urethra  will  also  cause  the 
tonic  contraction  of  the  sphincter  muscles  to  be  accentuated.     Hence 


INJURIES   AND    DISEASES    OF   THE    URETHRA.  71 

inflammatory  discharge  from  the  ir.embraiious  or  tlie  prostatic  urethra 
will  flow  not  forward,  but  into  the  bladder,  and  injections  intended 
to  reach  the  deep  urethra  will,  if  driven  in  at  the  meatus,  extend  no 
farther  back  than  the  anterior  laj^er  of  the  triangular  ligament. 

There  seem,  then,  to  be  good  grounds,  both  from  a  physiological 
and  from  a  clinical  stand-point,  for  dividing  the  urethra  into  an  an- 
terior erectile  part  and  a  posterior  muscular  part. 

Malformations  of  the  Urethra. — The  urethra  may  be  absent, 
obliterated,  congenitally  strictured,  sacculated,  or  deficient  as  to  its 
floor  or  its  roof.  Of  these  anomalies  deficiency  of  the  floor  and  of 
the  roof,  entitled  hypospadia  and  epispadia,  are  most  common. 

Absence  of  the  urethra  is  a  malformation  usually  fatal  to  the 
child  before  birth,  since  the  distended  bladder  by  pressing  on  the 
umbilical  arteries  interferes  with  the  foetal  circulation.  Exceptionally 
the  child  is  born  alive  with  a  greatly  dilated  bladder,  in  which  case 
the  urine  may  escape  through  a  patent  urachus,  or  by  way  of  the 
rectum  or  perineum,  fistulae  being  formed  ;  or  operation  by  supra- 
pubic or  perineal  puncture  may  give  relief. 

Treatment. — The  proper  treatment  for  absent  urethra  would  be 
the  formation  of  a  perineal  fistula,  the  position  of  the  base  of  the 
bladder  previously  having  been  determined  by  digital  examination 
through  the  rectum. 

Atresia  or  obstruction  of  the  urethra,  usually  at  one  point,  may 
occur  at  any  portion  of  the  canal,  but  is  commonly  observed  at  or 
near  the  meatus.  The  occlusion  may  be  caused  by  a  thin,  easily 
pierced  membrane,  the  variety  ordinarily  seen  near  the  meatus  or  in 
some  portion  of  the  anterior  urethra ;  or  the  urethra  itself  may  be 
converted  into  a  fibrous  cord,  a  form  rarely  observed,  except  in  or 
near  the  membranous  portion  of  the  canal.  In  these  cases  fistulas 
often  form,  giving  spontaneous  relief.  Frequently,  however,  there  is 
retention  of  urine,  with  all  its  disastrous  effects  upon  the  bladder 
and  kidneys  and  upon  the  system  at  large.  As  in  the  case  of  absent 
urethra,  the  condition  usually  causes  the  death  of  the  foetus. 

The  diagnosis  is  founded  upon  the  failure  of  the  child  to  urinate, 
the  presence  of  a  distended  bladder,  which  sometimes  completely 
fills  the  belly,  and  can  be  felt  by  abdominal  palpation  and  by  digital 
examination  through  the  rectum,  coUcky  pains,  and  the  discovery  of 
obstruction,  either  by  inspection,  when  the  stoppage  is  located  at  or 
near  the  meatus,  thus  allowing  the  urethra  to  become  distended  be- 
hind the  point  of  blocking,  or  by  instrumental  examination,  if  the 
visible  portion  of  the  urethra  seems  normal. 

Treatment. — The  treatment,  when  the  obstruction  is  at  or  near  the 


72  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

meatus,  consists  in  opening  the  obstructed  portion  of  the  urethra  by- 
means  of  a  trocar  and  canula,  a  tenotome,  or  a  small  sound.  When 
it  is  placed  deeper  it  would  seem  advisable  to  pass  a  sound  down  to 
its  anterior  face  and  make  an  attempt  by  gentle  pressure  exerted  in  the 
proper  direction  to  pas«  through  it.  Having  succeeded  in  introducing 
an  instrument  and  evacuating  the  urine  (not  all  at  one  sitting,  in  case 
of  great  bladder  distention),  the  sound  is  passed  through  the  seat  of 
obstruction  at  intervals  of  three  days  for  several  weeks. 

When  instruments  cannot  be  introduced,  the  membranous  and 
prostatic  portions  of  the  urethra  should  be  opened  by  external 
perineal  urethrotomy,  and  the  posterior  limit  of  the  obstruction  de- 
termined by  passing  an  instrument  from  behind  forward ;  or  if  the 
occlusion  extends  well  back  into  the  membranous  urethra  the  same 
result  may  be  accomplished  more  readily  by  performing  suprapubic 
cystotomy.  The  position  and  the  extent  of  the  urethral  obstruction 
having  been  exactly  determined  by  one  instrument  passed  from  the 
meatus  backward,  and  by  another  passed  from  the  membranous 
urethra  or  the  bladder  forward,  the  urethra  may  be  rendered  per- 
vious either  by  instruments  cutting  from  within,  a  long  knife  passed 
through  an  endoscopic  tube,  for  instance,  or  by  an  external  ure- 
throtomy, followed  by  plastic  operation.  Unless  the  obstruction  be 
limited  to  a  thin  membrane,  external  operation  will  be  required.  An 
attempt  may  be  made  to  repair  the  defect  in  the  urethral  lining  by 
transplanting  mucous  membrane  from  the  cheek.  This  is  held  in 
place  by  a  few  catgut  sutures  and  the  permanent  catheter,  the  skin 
opening  being  closed  by  suture.  The  catheter  is  left  in  place  six 
days.     Regular  dilatation  is  necessary  in  the  after-treatment. 

Congenital  strictures,  if  the  usual  narrowing  at  or  just  behind 
the  meatus  be  excepted,  are  extremely  rare.  If  present,  they  will  be 
denoted  by  slow  dribbling  urination,  with  increased  frequency,  dilata- 
tion of  the  bladder,  and  colicky  pains.  Such  strictures  should  be 
treated  by  gradual  dilatation ;  this  failing,  urethrotomy  is  indicated. 

Very  exceptionally  narrowing  of  the  meatus  becomes  so  extreme 
that  the  act  of  micturition  is  seriously  interfered  with.  There  is 
usually  an  associated  phimosis,  which  hides  the  real  seat  of  obstruc- 
tion. Meatotomy  should  be  performed  immediately,  the  meatus 
being  kept  patulous  by  the  regular  passage  of  bougies  till  healing 
is  complete. 

Valvular  folds  have  been  found  post  mortem  in  the  prostatic 
urethra,  with  characteristic  changes  of  bladder,  ureters,  and  kidneys, 
showing  that  they  had  occasioned  fatal  obstruction.  Such  folds  are 
also  found  about  the  junction  of  the  penile  and  the  glandular  urethra. 


INJURIES    AND   DISEASES   OF   THE   URETHRA.  73 

The  diagnosis  is  difficult,  and  will  be  founded  on  slow,  difficult, 
frequent  urination,  bladder  distention,  and  colicky  pains  associated 
Avith  a  urethra  which  readily  admits  a  small  sound. 

The  urethroscopic  tube  (No.  12  to  14  F.)  might  render  both  a 
diagnosis  and  treatment  by  cutting  practicable  in  the  case  of  prostatic 
valves.  The  bulbous  bougies  should  find  anterior  valves  ;  these  are 
readily  divided  by  a  tenotome. 

Urethral  pouches  or  diverticula  may  sometimes  reach  large  size. 
They  develop  from  the  floor  of  the  urethra,  and  in  the  cases  described 
were  found  just  behind  the  glans.  They  were  not  associated  with  stric- 
ture, but  seemed  to  be  dependent  for  their  formation  on  absence  of  the 
erectile  tissue,  leaving  a  thin  urethral  wall  which  gradually  dilated. 
These  congenital  pouches  are  associated  with  incontinence  of  urine. 
They  become  distended  with  each  act  of  micturition,  and  there  is  sub- 
sequent dribbling  from  the  slow  leakage  of  the  urine  contained. 

Diagnosis. — A  diagnosis  is  readily  made  from  the  distention  ob- 
served during  the  act  of  urination  and  from  the  absence  of  inflam- 
matory reaction. 

Treatment. — The  treatment  consists  in  removal  of  the  redundant 
walls  of  the  pouch  and  suture  of  mucous  membrane  and  skin  so  that 
the  calibre  of  the  resulting  urethra  at  the  point  of  operation  shall  be 
about  normal. 

As  an  unusual  anomaly  the  urethra,  on  inspecting  the  glans, 
seems  to  be  double  or  multiple.  Exploration  of  these  openings  will 
show  one  or  more  blind  pouches,  the  urethra  opening  by  a  single 
orifice.  Or  in  case  there  is  a  second  channel  passing  parallel  with  the 
urethra,  this  is  probably  a  continuation  of  the  ejaculatory  ducts. 

Hypospadia. — This  defect  depends  upon  a  congenital  deficiency 
of  the  floor  of  the  urethra,  which  channel,  instead  of  being  continued 
to  the  glandular  meatus,  opens  at  some  point  on  the  lower  surface  of 
the  penis.  The  deformity  is  fairly  common,  being  counted  by  Bouis- 
son  once  in  three  hundred  males.  It  is  distinctly  congenital.  Duplay 
describes  two  chief  forms  of  hypospadia  :  (1)  that  in  which  the  urethra 
is  absent  in  front  of  the  abnormal  opening,  this  being  the  common 
form,  and  (2)  that  in  which  the  urethra  exists  in  front  of  the  opening, 
an  extremely  rare  form. 

In  regard  to  the  position  of  the  opening,  hypospadia  is  classed  as 
(1)  balanic,  or  glandular,  the  urethra  terminating  at  the  base  of  the 
glans ;  (2)  penile,  the  urethra  terminating  at  a  point  between  the 
glans  and  the  peno-scrotal  junction  (Fig.  34) ;  (3)  perineal,  including 
under  this  heading  the  perineo-scrotal  forms,  where  the  urethra 
terminates  in  the  scrotal  cleft. 


74 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


Cause. — The  cause  of  hypospadia  is  obviously  an  arrest  of  devel- 
opment.    The  prostatic  and  membranous  portions  of  the  urethra,  the 


Fig.  34. 


Forms  of  penile  hypospadia.    S,  scrotum.    (Kaufmann.) 

penile  portion,  and  the  glandular  portion  are  each  developed  sepa- 
rately. The  anterior  urethra  represents,  in  the  early  part  of  its  devel- 
opment, simply  a  groove,  which  as  the  foetus  grows  older  is  closed 


INJ OKIES    AND    DISEASES    OF   THE   URETHRA. 


75 


from  behind  forward.  Failure  to  close  any  portion  of  this  groove,  or 
failure  of  any  of  the  three  separately  formed  portions  of  the  urethra 
to  unite,  will  occasion  hypospadia.  Kaufmann  attributes  hypospadia 
to  obstruction  of  the  urethra  persisting  after  urine  has  been  secreted 
by  the  kidneys.  In  consequence  of  retention  the  urethra  ruptures 
behind  the  seat  of  obstruction. 

Balanic  or  GLANDULAR  HYPOSPADIA  is  characterized  by  a  rather  broad 
glans,  curved  somewhat  downward,  and  covered  on  its  dorsal  surface 
by  a  thickened  hood,  representing  the  malformed  prepuce.  The  frse- 
num  is  absent,  and  the  urethra  terminates  usually  in  a  very  small 
opening  at  the  base  of  the  glans,  being  continued  forward  by  a  nar- 
row groove,  representing  the  upper  wall  of  the  navicular  fossa.  (Fig. 
34.")     A  normally  placed  meatus  is  often  found,  but  this  is  simply  a 

Fig.  35. 


Peno-scrotal  hypospadia. 

bhnd  pouch.  The  cavernous  bodies  are  well  formed.  Other  de- 
formities occasionally  complicate  balanic  hypospadia ;  thus,  the  penis 
may  be  twisted,  the  cavernous  bodies  may  be  stunted  or  absent,  the 
testicles  may  be  undescended,  or  the  penis  may  be  adherent. 

Penile  Hypospadia. — The  opening  is  usually  found  either  just  be- 
hind the  glans,  midway  between  the  glans  and  the  peno-scrotal  junc- 
tion, or  at  this  junction.  (Fig.  35.)  The  penis  in  these  cases  is  often 
curved  downward,  the  cavernous  bodies  are  sometimes  poorly  de- 


76  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

veloped,  and  nearly  always  the  prepuce  is  redundant.  Associated 
deformities  are  more  frequently  encountered  in  this  class  of  cases 
when  hypospadic  openings  are  placed  at  or  near  the  peno-scrotal 
angle.  Anterior  to  the  abnormal  opening  the  urethra  is  generally 
wanting  entirely,  or  it  may  appear  in  the  form  of  a  groove,  or  there 
may  be  a  fibrous  ridge  extending  from  the  glans  to  the  opening. 
Rarely  the  meatus  and  some  portion  of  the  urethra  back  of  this  may 
be  preserved,  terminating  in  a  blind  pouch ;  or  the  urethra  may 
continue  anterior  to  the  hypospadic  opening,  ending  in  a  cul-de-sac 
before  it  reaches  the  meatus ;.  or  the  urethra  may  be  continuous  to 
the  meatus,  hypospadia  then  simply  representing  congenital  fistula. 
The  scrotum  is  not  cleft  in  penile  hypospadia. 

Perineal  hypospadia  represents  the  most  inveterate  form,  and 
that  characteristic  of  the  most  marked  interference  with  development. 
The  scrotum  is  divided  by  a  deep  cleft  into  two  lateral  halves,  in  each 
of  which  there  may  be  placed  a  normal  testicle,  though  usually  these 
organs  are  only  partially  developed,  and  frequently  have  not  descended. 
In  this  case  the  scrotal  flaps  closely  resemble  the  labia  majora.  The 
penis  is  stunted,  except  in  its  glandular  portion,  and  is  curved  down- 
ward and  backward  towards  the  scrotal  cleft.  On  raising  it  there  is 
seen  a  funnel-shaped  depression,  in  the  deepest  part  of  which  the 
urethra  opens  by  a  vertical  slit,  provided  at  either  side  with  a  muco- 
cutaneous fold,  suggesting  the  arrangement  of  the  labia  minora. 
These  folds  pass  forward  along  the  under  surface  of  the  penis  and 
the  glans,  constituting  either  a  groove  or  a  ridge,  representing  the 
absent  urethra.  The  glans  is  broadened  and  incurved,  mainly  owing 
to  imperfect  development  of  the  lower  portion  of  the  cavernous 
bodies ;  here  the  fibrous  envelope  is  extremely  thick,  and  the  septum 
between  the  two  corpora  cavernosa  in  some  cases  participates  in  the 
contraction. 

Glandular  and  penile  hypospadia  do  not  necessarily  interfere  with 
either  micturition  or  the  procreative  function.  By  lifting  the  glans 
the  urine  may  be  projected  in  an  almost  normal  direction,  and,  unless 
incurvation  is  more  than  usually  marked,  sexual  congress  is  possi- 
ble, but  fecundation  is  doubtful.  In  the  scrotal  and  perineal  varie- 
ties the  functions  of  both  micturition  and  copulation  are  materially 
interfered  with.  The  backward  curve  of  the  urethra  obstructs  the 
stream,  which  is  driven  out  with  some  force  ;  the  urine  is  usually 
sprayed  in  all  directions,  requiring  the  patient  to  micturate  in  the 
sitting  position  if  he  wishes  to  avoid  soiling  his  clothing.  On  erection 
the  incurvation  of  the  organ  becomes  even  more  marked  than  before  ; 
thus  copulation  is  impossible. 


INJUEIES   AND    DISEASES    OF    THE    UKETHKA.  77 

Diagnosis. — The  diagnosis  is  not  difficult  to  make,  a  simple  in- 
spection, especially  when  the  patient  urinates,  sufficing,  although  in 
one  case  we  observed  a  practitioner  had  endeavored  for  three  years 
to  catheterize  a  penile  hypospadic  through  the  cul-de-sac  representing 
the  glandular  urethra. 

Under  some  circumstances  the  determination  of  sex  is  extremely 
difficult  in  cases  of  perineal  hypospadia.  Careful  examination  through 
the  rectum  combined  with  abdominal  palpation  will  in  some  cases 
show  the  presence  of  either  a  prostate  or  a  rudimentary  uterus,  thus 
enabling  the  surgeon  to  give  judgment  as  to  the  sex  which  the  case 
most  nearly  resembles. 

Prognosis. — The  prognosis  of  hypospadia,  from  both  a  functional 
and  a  cosmetic  stand-point,  is  fairly  good  when  the  testicles  have 
descended  and  are  normal  in  size. 

Treatment. — The  treatment  consists  in  correcting  the  incurvation 
and  restoring  the  urethra  to  its  natural  position  and  length.  This 
end  is  accomplished  by  plastic  operations.  These  should  be  performed 
in  successive  stages.  The  first  has  for  its  object  the  straightening  of 
the  penis ;  the  second  makes  a  new  canal  from  the  normal  position 
of  the  meatus  and  the  neighborhood  of  the  hypospadic  opening ;  the 
third  joins  this  newly  formed  canal  with  the  posterior  portion  of  the 
urethra. 

The  first  stage,  straightening  the  penis,  is  accomplished  by  a 
transverse  incision  across  the  under  surface  of  the  penis,  dividing  the 
fibrous  ridge  which  so  frequently  passes  from  the  hypospadic  opening 
to  the  glans,  and  including  in  this  division  the  thickened,  contracted 
sheath  covering  in  the  surface  of  the  cavernous  bodies,  and  also,  if 
necessary,  a  portion  of  the  septum  between  these  two  bodies.  The 
incision  can  be  carried  as  deep  as  is  necessary  for  complete  straighten- 
ing of  the  curve.  This  often  implies  section  into  the  substance  of  the 
cavernous  bodies.  When  the  penis  has  been  straightened  the  wound 
is  united  by  means  of  sutures,  so  that  its  long  axis  is  at  right  angles  to 
the  line  of  the  original  incision.  (Figs.  36,  37.)  The  wound  is  dressed 
with  a  narrow  strip  of  sterile  gauze  secured  in  place  by  a  film  of 
cotton  over  which  is  painted  collodion.  A  few  turns  of  a  narrow 
gauze  bandage  are  then  applied,  and  the  penis  is  held  upward  against 
the  body  between  two  layers  of  cotton,  a  crossed  of  the  perineum 
roller  bandage  or  a  jock-strap  securing  it  in  place.  Stitches  are 
removed  in  five  days.  The  penis  is  subsequently  held  by  dressings  in 
the  same  position  till  the  next  step  in  the  operation  is  undertaken. 

At  the  time  the  penis  is  straightened  a  portion  of  the  second 
stage — i.e.,  the  formation  of  the  glandular  urethra — is  accomplished. 


78 


GENlTO-UKlNAPvY   DISEASES   AND  SYPHILIS. 


Where  there  is  a  deep  furrow  representing  the  roof  of  the  urethra, 
freshening  of  its  lower  edges  and  apposition  by  suture  may  be  suffi- 
cient. Usually  a  deep  vertical  incision  or  two  lateral  incisions,  one 
on  the  upper  and  outer  wall  of  each  side  of  the  groove,  will  be 
required.     In  the  furrow  thus  deepened  is  laid  a  section  of  catheter 


Fig.  36. 


Fig.  37. 


Penis  straightened  after  transverse  cut 
of  lower  surface. 


Transverse  wound  sutured  longitudinally  ; 
glandular  urethra  formed. 


corresponding  in  circumference  to  the  normal  calibre  of  the  urethra, 
and  the  freshened  edges  of  the  furrow  are  neatly  approximated  by 
suture,  two  or  three  silk  threads  being  used.  (Fig.  38.)  These  are 
removed  in  five  days.  It  is  often  difficult  to  keep  the  section  of 
catheter  in  the  penile  urethra  thus  made.     This  trouble  may  be 

Fig.  38. 


V 


Freshened  areas  and  incisions  made  m 
forming  glandular  urethra 


<  jilandular  urethra  closed  by 

sxitures. 


overcome  by  taking  a  piece  of  small  catheter  sufficiently  long  to 
tie  a  knot  in  each  end.  Before  proceeding  to  the  formation  of  the 
penile  urethra  it  is  well  to  wait  for  some  months,  to  determine 
whether  or  not  incurvation  of  the  penis  will  be  reproduced  by 
contraction. 

The  second  stage — i.e.,  the  formation  of  a  canal  from  the  glans  to 


INJURIES  AND    DISEASES  OF   THE    URETHRA. 


79 


the  bladder — is  performed  by  Duplay  as  follows  :  Through  a  perineal 
opening  a  Guyon  self-retaining  catheter  is  placed  in  the  bladder.  The 
penis  is  held  up,  and  two  parallel  incisions  are  made  in  the  lower  sur- 
face, each  one-eighth  of  an  inch  from  the  middle  line  and  extending 
from  the  glans  to  within  a  short  distance  of  the  hypospadic  opening. 
From  the  ends  of  each  of  these  a  transverse  incision  is  made  towards, 
but  not  quite  to,  the  median  line.  This  leaves  a  median  strip  of  skin 
a  quarter  of  an  inch  wide,  which  is  to  serve  as  the  roof  and  sides 
of  the  new  urethra.  Short  flaps  are  raised  from  these  incisions 
towards  the  middle  line,  the  skin  being  dissected  free  on  each  side 
for  about  a  sixteenth  of  an  inch,  and  long  flaps  are  raised  away  from 
the  middle  line.     (Fig.  39.)     A  catheter  of  normal  urethral  calibre, 


Fig.  39. 


Fig.  40. 


Formation  of  penile  urethra.— Flaps  on  the 
left  side  of  the  penis  dissected  up,  the  short  one 
towards  the  catheter,  the  long  one  away  from  it. 


Formation  of  penile  urethra  completed. 


from  12  F.  to  16  F.,  depending  on  the  size  of  the  penis,  is  passed 
through  the  artificially  formed  glandular  urethra  and  along  the  course 
of  the  proposed  penile  portion  of  the  tube.  The  two  inner  flaps  are 
lifted  so  that  their  skin  surfaces  are  in  apposition  with  the  sides  of 
the  catheter.  No  effort,  however,  is  made  to  form  them  of  suffi- 
cient length  completely  to  encircle  the  instrument.    The  long  external 


80  GENITO-LTEINARY  DISEASES   AND   SYPHILIS. 

flaps  are  then  brought  over  the  catheter,  and  should  be  loosened  so 
thoroughly  that  they  cover  it  and  the  shorter  inner  flaps  completely 
without  undue  tension.  The  anterior  extremities  of  all  the  flaps  are 
then  united  to  the  freshened  border  of  the  glans,  thus  completing  the 
anterior  portion  of  the  tube. 

The  stitches,  of  very  fine  silver  wire,  do  not  include  the  edges  of 
the  short  inner  flaps.  They  are  placed  a  fifth  of  an  inch  apart,  and 
are  passed  through  apertures  in  small  pieces  of  lead  tubing  or  in 
sections  of  soft  rubber  catheter  (No.  12  F.),  one  on  each  side  of 
the  wound,  and  of  the  same  length  as  the  latter.  The  edges  of  the 
long  flaps  are  accurately  adjusted  and  held  in  place  by  shot  slipped 
over  the  ends  of  the  sutures  and  clamped  against  the  lead  pipes  or 
pieces  of  catheter,  thus  forming  a  modified  quill  suture,  (Fig.  40.) 
Ordinary  interrupted  catgut  sutures  may  be  applied  wherever  the 
apposition  is  not  perfect.  These  are  always  required  to  unite  the 
anterior  portion  of  the  skin  flaps  to  the  posterior  lower  portion  of  the 
glans  and  to  the  hypospadic  opening,  which  must  be  freshened  before 
the  sutures  are  passed.  By  this  operation  a  canal  is  formed,  partly 
of  the  raw  surface  of  the  two  external  long  flaps  and  partly  of  the 
skin  surface  of  the  two  short  inner  flaps.  A  strip  of  iodoform  gauze 
is  placed  over  the  line  of  suture,  and  is  secured  in  place  by  a  film  of 
sterile  cotton  and  iodoform  collodion.  The  catheter  over  which  the 
new  urethra  is  formed  is  withdrawn  tifl  its  eye  lies  just  to  the  blad- 
der side  of  the  new  urethra,  and  is  held  in  place  by  threads  which 
are  fastened  to  the  sides  of  the  penis  by  cotton  film  and  collodion. 
As  a  final  dressing  after  the  application  of  iodoform  collodion,  the 
penis  may  be  covered  in  by  a  few  turns  of  a  very  narrow  gauze 
bandage. 

The  first  stage  of  this  operation  should  be  undertaken  at  about  the 
fourth  year,  the  next  stage  six  to  ten  months  later.  The  final  stage 
may  be  reserved  till  puberty  ;  though  most  surgeons  prefer  to  perform 
it  as  soon  as  it  is  evident  that  the  results  of  the  earlier  operative  inter- 
ference are  satisfactory. 

Wood's  operation  for  hypospadias  is  applicable  particularly  when 
the  defect  is  in  the  anterior  half  of  the  urethra.  Two  lateral  flaps 
are  made  from  the  skin  of  the  under  surface  of  the  penis,  along  the 
urethral  groove  well  back  to  the  opening.  Upon  being  turned  so  that 
the  skin  surface  is  toward  the  new  canal,  their  edges  are  united  by  a 
fine  catgut  suture.  The  redundant  dorsal  prepuce  is  then  button-holed 
by  a  transverse  incision  close  to  the  coronal  groove  and  the  glans 
passed  through.  The  transposed  hood  of  dorsal  prepuce  is  sepa- 
rated into  two  layers  at  its  cut  edge,  opened  and  spread  out  over  the 


INJUKIES    AND  DISEASES    OF    THE    URETHKA.  81 

new  surface  of  the  reversed  urethral  flaps,  and  united  to  the  cut  edges 
of  the  under  surface  of  the  penis  by  fine  closely  applied  sutures.  If 
the  preputial  flap  is  insufficient  to  cover  the  raw  surface  entirely,  a 
small  flap  from  the  scrotum  may  be  made  to  supply  the  deficiency. 

Becks  operation  is  particularly  serviceable  after  the  fifth  year  when 
the  hypostadic  opening  is  close  to  the  glans.  The  procedure  is  based 
on  the  fact  that  the  penile  part  of  the  urethra  is  very  extensible,  easily 
separated  from  its  surroundings,  and  so  well  vascularized  that  its  nutri- 
tion is  not  threatened  by  such  separation, 

A  transverse  incision  is  made  on  the  lower  surface  of  the  penis  at 
the  base  of  the  glans,  and  a  longitudinal  incision  extended  from  its 

Fig   41 


■f-     mimmmjupiii 
Glandular  epispadia.     (Kaufmaiui.) 


center  as  far  back  as  necessary.  The  urethra  is  then  exposed  and 
freed  from  its  attachments  for  a  sufficient  distance.  A  double-edged, 
narrow  bistoury  is  passed  longitudinally  through  the  glans  and  brought 
out  at  the  transverse  incision.  A  pair  of  fine  forceps  is  passed  back- 
ward through  this  canal,  and  the  end  of  the  urethra  grasped  by  them 
is  drawn  through  the  glans  and  sewed  securely  to  the  mucous  mem- 
brane around  the  edges  of  the  incision.  The  longitudinal  incision, 
which  generally  extends  to  the  scrotum,  is  then  sutured  with  separate 
catgut  stitches,  each  stitch  catching  the  urethra  superficially  but  not 
puncturing  it.  The  transverse  incision  is  then  sutured  and  the  wounds 
dressed.  An  antiseptic  placed  over  the  end  of  the  penis  is  changed  at 
each  act  of  urination. 

Epispadia.— In  this  deformity  a  portion  or  all  of  the  roof  of  the 
urethra  is  absent,  the  canal  being  represented  by  a  furrow  traversing 

6 


82 


GEIS'ITO-UKINAKY   DISEASES   AND    SYPHILIS 


the  mid-dorsal  aspect  of  the  penis.  It  is  often  comphcated  by  ex- 
strophy of  the  bladder,  and  is  sometimes  associated  with  other  mal- 
formations, such  as  urachal  fistula,  imperforate  anus,  absence  of  the 
prostate,  abnormalities  of  the  corpora  cavernosa,  etc.  This  anomaly, 
rare  in  all  its  forms,  may  appear  as  the  glandular  form, — i.e.,  the 
urethra  is  complete  as  far  as  the  glans,  opening  just  behind  this 
expansion  of  the  spongy  body  (Fig.  41)  ;  more  often  the  alDuormal 
opening  is  just  in  front  of  the  pubic  symphysis  (Fig.  42),  or  rather  in 
the  normal  position  of  this  junction,  since  in  many  of  these  cases  the 
pubic  rami  do  not  extend  to  the  middle  line. 

In  these  cases  the  penis  is  short,  broad,  curved  upward,  at  times 
twisted ;  the  prepuce  is  redundant  below,  and  there  is  a  projecting 

Fig.  42. 


Usual  fiini)  1)1'  episiiadia. 

belly-fold  above,  against  which  the  dorsum  of  the  glans  is  apposed. 
On  drawing  this  down  the  urethral  furrow  is  seen  lined  with  thin 
mucous  membrane  and  passing  backward  to  the  urethral  orifice 
deeply  sunken  in  the  pubic  region.  This  orifice  is  usually  large,  often 
admitting  an  examining  finger  without  difficulty.  In  case  the  poste- 
rior urethra  is  involved,  there  is  exstrophy  of  the  bladder,  ordinarily 
with  absence  of  the  pubic  symphysis. 

Epispadia  is  often  attended  with  incontinence  of  urine,  though 
when  the  posterior  urethra  is  perfectly  formed  and  there  is  no  separa- 


INJUEIES    AND    DISEASES    OP    THE    UllETHRA.  83 

tion  of  the  pubic  bones  micturition  may  be  accomplished  normally. 
Except  in  cases  of  marked  curvation  of  the  penis,  erection  and  intro- 
mission are  possible. 

Treatment. — The  treatment  of  epispadia  is  either  palliative — i.e., 
the  adaptation  of  a  properly  fitting  portable  urinal  (see  Exstrophy, 
page  394) — or  radical, — i.e.,  by  operative  measures. 

Operation. — The  penis  is  straightened  by  one  or  more  deep  trans- 
verse cuts  across  the  dorsum,  sutured  so  that  the  ends  of  the  incision 
are  approximated,  as  in  hypospadia.  After  a  sufficient  lapse  of  time 
(see  above  as  to  hypospadia)  the  edges  of  the  urethral  fissure  are 
freshened  and  approximated  over  a  catheter.  In  this  case,  however, 
the  catheter  is  passed  into  the  bladder  through  the  epispadic  opening, 
and  is  kept  in  place  till  the  apposed  freshened  surfaces  have  united. 
The  redundant  prepuce  is  button-holed  to  an  extent  sufficient  to  admit 
the  glans  penis  ;  the  latter  is  then  passed  through  this  opening,  the 
preputial  layers  are  split,  and  the  resulting  raw  surface  is  apposed. 
to  the  dorsal  coronal  surface  of  the  glans  penis  and  the  anterior  bor- 
der of  the  newly  formed  penile  urethra,  which  are  denuded  to  a 
sufficient  extent  to  receive  this  large  graft.  Thus  the  redundant  pre- 
puce is  disposed  of,  and  the  penile  urethra  and  the  glandular  urethra 
are  covered  with  skin. 

Finally,  the  borders  t)f  the  opening  remaining  between  the  original 
urethra  and  the  part  newly  formed  are  freshened  and  approximated 
by  interrupted  sutures. 

Cantwell's  operation  is  preceded  by  the  insertion  of  a  permanent 
perineal  drain.  Beginning  at  the  opening  in  the  bladder,  incisions  are 
carried  on  each  side  of  the  penis  at  the  junction  of  the  urethral  groove 
and  skin  to  the  glans  penis,  where  they  are  joined  by  a  transvere  cut. 
The  tissue  between  the  incisions  is  dissected  back  almost  to  the  blad- 
der-wall, and  the  flap  thus  formed  is  converted  into  a  tube  by  suturing 
its  edges  over  a  catheter  with  fine  catgut.  The  corpora  cavernosa  are 
then  separated  throughout  their  whole  length  and  the  glans  is  either 
incised  or  tunnelled.  The  new  urethra  is  buried  between  the  cavern- 
ous bodies  and  the  raw  surface  is  covered  by  skin  suture.  If  the  ure- 
thra is  too  short,  a  pedunculated  flap  may  be  taken  from  the  prepuce, 
converted  into  a  tube,  and  drawn  through  the  tunnelled  glans,  being 
then  united  to  the  distal  end  of  the  urethra  already  formed.  The  peri- 
neal drain  is  removed  in  about  ten  days. 

The  Thiersch  method  is  still  a  favorite  one,  and  gives  excellent 
results.  Thiersch  states  that  by  his  method  a  new  urethra  is  formed 
which  corresponds  closely  with  the  normal  channel  in  calibre,  func- 
tion, and  position.     (Fig.  43.) 


84 


GEXITO-UEI^'AEY   DISEASES   AXD   SYPHILIS. 


There  are  three  distinct  periods  of  the  operation. 

The  first  period  is  devoted  to  the  formation  of  a  perineal  fistula. 
This  is  readily  done  by  inserting  into  the  bladder  a  curved  forceps. 
The  end  of  the  latter  is  pressed  downward  and  forward  into  the  peri- 
neum and  cut  upon,  care  being  taken  not  to  injure  the  rectum.  This 
can  be  guarded  against  by  passing  a  finger  of  the  left  hand  into  the 
anus  while  the  perineal  cut  is  being  made.  The  bladder  ha\ing  been 
thus  opened,  a  Guyon  self-retaining  rubber  catheter  is  introduced.  If 
there  has  been  excoriation  of  skin  from  leaking  and  decomposition  of 
urine,  it  is  well  to  postpone  the  further  steps  of  the  operation  until 
thorough  cleansing  of  the  parts  and  the  application  of  astringent  and 
mildly  antiseptic  dusting  powders  have  subdued  all  irritation.  This 
perineal  fistula,  by  diverting  the  urine  from  the  seat  of  subsequent 
operations,  enables  the  surgeon  to  avoid  the  dangers  and  delays  inci- 
dent to  suppuration,  which  almost  inevitably  occurs  when  the  urine 
is  allowed  to  escape  in  its  natural  course. 

Fig.  43. 


Formation  of  glandular  urethra.— A.  1-1,  2-2,  freshened  siirface  on  each  side  of  the  penile 
furrow.  B.  Cross-section  of  glans,  sho^^■ing  depth  and  direction  of  incisions  1-1  and  2-2.  C.  Glan- 
dular urethra  formed.    (Thiersch.) 

The  second  step  of  the  operation  consists  in  the  formation  of  a 
glandular  urethra.  To  the  right  and  left  of  the  glandular  furrow,  par- 
allel with  the  latter,  running  the  whole  length  of  the  glans,  and  in 
depth  equalling  three-fourths  of  its  thickness,  there  are  made  incisions 
converging  to  such  an  extent  that  were  they  continued  to  the  lower 
surface  of  the  glans  they  would  meet.  (Fig.  43.)  By  these  cuts  there 
are  formed  two  lateral  flaps  and  a  middle  wedge-shaped  piece  of  gland- 
ular tissue,  the  broad  base  of  the  latter  looking  upward  and  being  cov- 
ered with  epidermis.  Along  the  outer  border  of  each  incision  there  is 
removed  a  strip  of  the  glandular  covering,  so  that  when  these  lateral 
flaps  are  brought  together  fresh  surfaces  of  sufficient  breadth  to  assure 
firm  union  will  be  apposed.  These  lateral  flaps  are  approximated  over 
the  middle  wedge  and  united  by  two  or  three  harelip  pin  sutures. 
The  canal  thus  formed  is  more  deeply  placed  at  its  orifice  than  in 
the  region  of  the  corona,  though  this  is  of  minor  consequence. 
Obliteration  of  this  canal  is  impossible,  since  the  epithelial  covering 
of  the  middle  wedge  prevents  it. 


INJUKIES   AND    DISEASES   OF    THE    UEETHKA. 


85 


The  next  step  of  the  operation  consists  in  transforming  the  penile 
furrow  into  a  canal.  Close  to  the  right  border  of  the  furrow  there  is 
made  a  longitudinal  incision  dividing  the  skin  and  the  subcutaneous 
tissues  the  entire  length  of  the  furrow.  (Fig.  44.)  From  either  end 
of  this  incision  a  trr.nsverse  cut  is  made  running  outward,  thus  out- 
lining a  long  quadrilateral  flap.  This  is  dissected  up  with  as  much 
subcutaneous  tissue  as  possible,  especially  near  the  base  of  the  flap. 


Fig.  44. 


Fig.  45. 


Outlining  of  flaps  to  form  penile  urethra. 
— A,  flap  dissected  outward  ;  B,  flap  dissected 
inward. 


A.  Flaps  folded  over  and  held  in  position 
by  sutures. — Long  flap  drawn  to  the  left  side 
of  the  penis  ;  stitches  holding  the  short  inner 
flap  in  position. 


Cross-section  of  same,  showing  the  direction 
in  which  the  flaps  are  dissected. 


Cross-section  of  same. 


A  similar  long  incision  is  made  to  the  left  of  the  furrow,  about  two- 
fifths  of  an  inch  from  its  edge.  From  each  end  of  this  incision  a 
transverse  cut  is  carried  inward  as  far  as  the  edge  of  the  furrow. 
This  flap  is  also  dissected  up  with  as  much  subcutaneous  tissue  as 
possible.  It  is  then  turned  over  exactly  as  one  turns  the  leaf  of  a 
book  from  right  to  left,  so  that  its  epithelial  surface  forms  the  roof 
of  the  furrow,  while  its  wound  surface  is  turned  outward.  If  the  flap 
is  sufficiently  wide  to   cover  in  the  furrow  entirely  without   undue 


86  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

tension,  three  or  four  threads  with  a  needle  on  each  end  are  passed 
through  its  free  border.  The  first  flap  is  nov/  drawn  directly  over 
this  flap  which  has  been  turned  over,  thus  approximating  the  two 
fresh  surfaces  of  the  flaps  and  covering  the  whole  with  skin.  (Fig.  45.) 
Before  suturing  this  flap  in  position  the  needles  attached  to  the  sutures 
passing  tlirough  the  free  border  of  the  reflected  flap  are  passed  from 
within  outward  through  the  base  of  the  first  flap,  each  stitch  including 
a  very  narrow  bridge  of  the  skin.  These  sutures  are  tied  down,  the 
first  flap  while  they  are  inserted  and  secured  being  held  with  exactly 
the  same  tension  as  is  necessary  for  its  final  suture.  Finally  the 
superficial  flap  is  secured  by  suture  to  the  skin  border  from  which 
the  reflected  flap  was  turned  in. 

The  canal  thus  formed  is  closed  with  skin  both  within  and  without, 
and  is  of  the  right  calibre.  There  is  no  danger  of  the  flaps  sloughing 
provided  they  have  been  left  sufficiently  thick  at  their  base  and  have 
been  dissected  so  freely  that  there  is  no  tension.  Should  there  be 
dangerous  tension,  two  long  incisions  are  made  to  the  right  and  left 
of  the  lower  mid-line  of  the  penis.  These  are  carried  down  to  the 
fibrous  sheath,  and  are  allowed  to  heal  by  granulation. 

The  next  step  of  the  operation  consists  in  the  union  of  the  glan- 
dular and  penile  urethras.  This  is  made  at  the  expense  of  the  fore- 
skin. The  transverse  defect  existing  between  the  penile  and  the 
glandular  urethra  is  first  completely  and  widely  freshened.  The 
foreskin  is  stretched  out  and  an  oblique  incision  is  made  entirely 
through  it,  forming  an  opening  sufficiently  large  to  allow  the  glans 
to  slip  through.  (Fig.  46.)  The  lower  half  of  the  foreskin  is  thus 
by  its  raw  surface  closely  applied  to  the  corona.  The  foreskin  having 
been  brought  up  in  place,  one  of  its  layers  is  carefully  sutured  to  the 
upper  border  (formed  by  the  new  urethral  roof)  of  the  defect,  and 
the  other  border  is  secured  to  the  freshened  corona  glandis.  (Fig.  47.) 
It  is  necessary  carefully  to  separate  the  two  layers  of  the  foreskin, 
otherwise  they  will  unite  to  each  other  instead  of  to  the  freshened 
surfaces.  This  portion  of  the  operation  also  has  cosmetic  virtues, 
since  it  gives  the  penis  a  more  normal  appearance. 

The  final  step  of  the  operation  consists  in  closing  the  posterior 
defect.  This  is  accomplished  by  means  of  two  flaps  cut  from  the 
surrounding  belly  walls.  The  first  flap  is  formed  from  the  left  side. 
It  is  in  the  shape  of  an  equilateral  triangle,  with  its  base  correspond- 
ing to  the  left  half  of  the  skin  surface  lying  immediately  above  and  to 
the  left  of  the  roof  of  the  urethral  orifice.  (Fig.  48.)  The  corner  of 
this  flap  is  folded  downward  and  inward  so  that  its  skin  surface 
covers   iii   the    defect.      Its   lower    free    border  is    sutured    to   the 


INJURIES   AND   DISEASES   OE   THE    URETHRA. 


87 


freshened  upper  border  of  the  new  roof  formed  by  transplantation 
of  the  penile  skin.      The  second  flap  approximates  the  form  of  a 


Fig.  40. 


Fig.  47. 


1.  Transverse  defect  between  penile  and  Foreskin  brought  up  behind  the  glans,  and 

glandular    urethras;    2,    3,    oblique    incision  lineof  sutures  uniting  freshened  edges  of  trans- 

through  foreskin.    (Thiersch.)  verse  defect  to  foreskin. 


quadrilateral  with  its  attached  base  in  the  region  of  the  right  inguinal 
canal.    This  flap  is  drawn  downward  and  inward  so  that  its  freshened 


Fig.  48. 


Closing  posterior  defect.— Formation  of  flaps 
X  and  Y;  suture  of  first  flap. 


Fig.  49. 


Suture  of  second  flap. 


surface  covers  in  the  fresh  surface  of  the  first  flap.    It  is  secured  in 
this  position  by  sutures,  including  both  the  lower  flap  and  the  bor- 


88  GElSriTO-UEINAEY   DISEASES   AND   SYPHILIS. 

ders  of  the  skin  incision  required  for  the  preparation  of  the  triangular 
flap.  (Fig.  49.)  The  raw  surface  left  after  this  transplantation  is 
allowed  to  heal  by  granulation. 

Healing  of  the  perineal  fistula  completes  the  operation.  This  is 
readily  accomplished  by  removing  the  tube. 

It  cannot  be  expected  that  this  operation  will  be  at  once  and  com- 

FiG.  50. 


*^«S^*Js*A-»^  ■ 


Cured  epispadia.    (Thiersch.) 

pletely  successful.     Fistulse  often  form  ;  portions  of  the  flaps  often  fail 
to  unite.     The  time  of  cure  is,  therefore,  apt  to  be  protracted. 

In  Thiersch's  own  case  (Fig.  50)  it  required  about  one  and  a  half 
years.  He  holds  that  ordinarily  it  should  be  accomplished  in  three 
or  four  months.  He  advises  that  the  various  steps  of  the  operation 
be  performed  in  the  order  given,  allowing  fourteen  days  for  the  for- 


INJUEIES   AND   DISEASES   OP    THE    UKETHRA.  §9 

mation  of  the  perineal  fistula,  fourteen  days  for  forming  the  glandular 
urethra,  twenty-one  days  for  closure  of  the  perineal  furrow,  fourteen 
days  for  transplantation  of  the  foreskin,  and,  finally,  for  the  closure  of 
the  urethra  and  the  subsequent  operations  which  may  be  necessary, 
forty-two  days. 

Rosenburg,  after  perineal  drainage,  denudes  the  borders  of  the 
penile  furrow  as  far  back  as  the  abdominal  wall,  from  which  he 
excises  two  quadrilateral  strips  of  skin  corresponding  in  dimensions 
with  the  denuded  penile  areas.  The  penis  is  turned  up  against  the 
abdominal  wall  and  the  raw  surfaces  are  held  in  apposition  by  suture. 
In  two  weeks  the  penis  is  dissected  from  its  abdominal  position,  a 
portion  of  skin  being  removed  with  it  of  sufficient  size  to  be  turned 
in  and  cover  the  raw  surface  representing  the  new  urethral  roof. 

INJURIES   OF  THE   URETHRA. 

The  urethra  may  be  wounded  or  subcutaneously  ruptured. 

Wounds  of  the  urethra  are  surgical  or  accidental.  Accidental 
wounds  are  rare. 

Incised  wounds  of  the  urethra,  if  longitudinal,  heal  readily  and 
often  without  subsequent  stricture,  even  though  no  sutures  are  ap- 
plied. When  such  injuries  are  inflicted  from  without,  either  inten- 
tionally by  the  surgeon,  as  in  the  case  of  external  urethrotomy,  or  as 
a  result  of  accident,  provided  the  urethra  is  healthy  and  the  urine 
sterile,  the  wound  may  be  sutured,  the  urethra  being  first  closed  by 
fine  buried  catgut  sutures,  not  including  the  epithelial  coat,  and  the 
skin,  subcutaneous  tissues,  and  spongy  body  being  approximated  by 
a  second  row  of  interrupted  fine  silkworm-gut  sutures.  Continuous 
catheterization  is  kept  up  from  two  to  five  days.  When  the  urethra 
is  suppurating  the  wound  should  be  allowed  to  heal  by  granulation. 
When  the  urethral  wound  is  not  extensive  it  is  not  necessary  to 
employ  stitches. 

When  the  urethra  is  incised  transversely  there  is  free  bleeding, 
and,  if  the  canal  is  cut  completely  across,  the  proximal  end  retracts. 
Heahng  by  granulation  always  imphes  a  degree  of  coarctation  de- 
pending on  the  extent  of  the  wound.  When  the  urethra  is  completely 
divided,  the  proximal  end  may  be  found  by  posterior  catheterization 
through  a  suprapubic  opening  in  case  it  has  retracted  so  that  it  is  not 
easily  secured  in  the  wound.  The  divided  urethral  ends  must  then 
be  held  in  neat  apposition  by  interrupted  catgut  sutures  placed  one- 
eighth  of  an  inch  apart  and  not  penetrating  the  epithelial  layer.  When 
the  continuity  of  the  roof  of  the  urethra  is  thus  restored  by  three  or 
four  sutures,  a  soft  catheter  is  passed  into  the  bladder,  the  urethral 


90  GENITO-URINAPvY   DISEASES   AJfD   SYPHILIS. 

suture  is  completed,  the  external  wound  is  closed,  and  the  catheter  is 
tied  in  place  ;  as  in  all  cases  of  continuous  catheterization,  the  bladder 
and  urethra  receive  frequent  antiseptic  irrigations. 

Always  after  the  healing  of  transverse  wounds  of  the  urethra  in- 
volving more  than  one-third  of  the  circumference  of  the  canal  a  sound 
should  be  passed  at  first  once  a  week,  then  at  longer  intervals,  till 
there  is  no  marked  tendency  to  stricture  formation. 

Lacerated  and  contused  wounds  of  the  urethra  are  cleansed, 
opened  so  that  drainage  both  of  urine  and  of  wound  discharges  is 
freely  provided  for,  and  allowed  to  heal  by  granulation,  continuous 
catheterization  being  maintained  till  the  urethral  defect  is  entirely 
closed  in.  Patients  after  these  injuries  must  be  instructed  in  the 
use  of  the  sound,  since  it  will  be  necessary  for  this  instrument  to  be 
passed  at  regular  intervals  for  probably  the  rest  of  their  lives. 

Whenever,  because  of  the  limited  extent  of  a  lacerated  and 
contused  wound,  there  is  sufficient  tissue  left,  after  trimming  away 
that  which  is  devitalized,  to  allow  of  urethral  suture,  this  procedure 
should  always  be  adopted,  since  thus  subsequent  stricture  may  be 
lessened. 

Punctured  wounds,  when  from  without,  are  not  attended  by  ex- 
travasation, and  require  simply  the  application  of  wet  antiseptic  and 
evaporating  lotions,  as,  for  instance,  lead  water  and  alcohol,  to  limit 
inflammatory  reaction.  When  the  urine  is  sterile  no  intra-urethral 
treatment  is  required.  When  it  is  infected,  and  particularly  when  the 
urethra  is  inflamed,  as  in  acute  or  chronic  gonorrhoea,  irrigation  with 
protargol  solution  1  to  2000,  or  bichloride  1  to  20,000,  is  indicated. 

When  the  punctured  wound  is  from  within,  as  in  the  formation 
of  a  false  passage,  free  bleeding  and  the  detection  of  the  point  of 
the  instrument  outside  the  urethra  by  external  or  rectal  palpation 
show  the  nature  of  the  injury.  Usually  such  wounds  heal  sponta- 
neously without  becoming  infected  even  though  infection  of  the  ure- 
thra has  existed  previously.  Exceptionally  they  suppurate,  forming 
abscesses. 

The  treatment  of  such  wounds  consists  in  refraining  from  further 
instrumentation,  making  the  urine  shghtly  antiseptic  by  appropriate 
medication,  and  using  mild  antiseptic  irrigation,  1  to  2000  protargol 
or  1  to  6000  permanganate,  under  low  pressure  (elevation  of  reser- 
vou*,  three  feet).  In  case  of  local  and  general  symptoms  pointing  to 
suppuration,  drainage  must  be  provided  for  by  external  incision. 

Rupture  of  the  Urethra. — Subcutaneous  rupture  of  the  urethra 
when  seen  in  the  penile  portion  of  the  canal  is  usually  the  result  of 
the  breaking  of  chordee,  fracture  of  the  penis,  or  twisting,  wrenching. 


INJUKIES    AND    DISEASES   OF    THE    UKETHEA.  91 

or  pinching  force  applied  to  the  erect  organ.  The  penis  is  so  mova- 
ble that  it  usually  escapes  the  crushing  effect  of  force  applied  in 
the  form  of  blows  and  kicks.  Subcutaneous  rupture  is  commonly- 
observed  in  the  perineal  urethra.  Kaufmann,  as  the  result  of  a  sta- 
tistical study  of  over  two  hundred  cases,  gives  as  the  form  of  injury, 
falling  astride  eighty  per  cent.,  perineal  blows  twelve  per  cent.,  being 
run  over  by  vehicles  four  per  cent.,  being  unseated  upon  the  pom- 
mel of  the  saddle  four  per  cent. 

The  mechanism  of  the  perineal  rupture  depends  upon  the  shape 
of  the  vulnerating  body  and  the  direction  in  which  the  force  is  applied. 
Where  there  is  a  fall  astride  upon  a  narrow  body,  as,  for  instance,  the 
edge  of  a  half-inch  plank,  this  is  forced  upward  between  the  ischio- 
pubic  rami,  usually  a  little  to  one  side,  tears  the  triangular  ligament, 
and  crushes  the  urethra  against  the  ischio-pubic  ramus.  When  the 
vulnerating  body  is  larger,  as,  for  instance,  the  square  toe  of  a  boot, 
the  urethra  is  driven  directly  upward  against  the  lower  or  anterior 
surface  of  the  pubis,  the  lower  portion  of  the  urethra  rupturing  first. 
Together  with  the  urethral  rupture  there  are  always  contusion  of  the 
bulb,  of  the  perineal  tissues,  and  often  of  the  attachment  of  the  cav- 
ernous bodies. 

The  seat  of  contusion  and  laceration  of  the  urethra  is  usually  in 
the  bulbous  part  of  the  urethra,  except  when  there  is  fracture  of  the 
pelvis  or  disjunction,  temporary  or  permanent,  of  the  pubic  symphy- 
sis, in  which  cases  the  membranous  urethra  is  involved. 

The  rupture  may  be  partial  or  complete.  In  the  mildest  cases  the 
spongy  tissue  is  the  only  part  involved.  There  results  in  consequence 
a  temporary  narrowing  or  blocking  of  the  urethra,  due  to  circum- 
scribed blood  effusion  into  the  loose  erectile  tissue  of  the  spongy  body. 
In  more  severe  cases  both  the  spongy  body  and  the  mucous  and  sub- 
mucous layers  of  the  urethra  are  crushed  and  torn.  In  the  most 
severe  cases  not  only  is  the  urethra  with  the  surrounding  spongy  body 
injured,  but  likewise  the  fibrous  investment  of  the  latter,  thus  making 
a  direct  communication  from  the  floor  of  the  urethra  to  the  loose  cel- 
lular tissue  of  the  scrotum  and  the  peritoneum. 

The  rupture  may  involve  the  entire  lumen  of  the  tube,  or,  as  is 
more  frequently  the  case,  may  include  only  its  lower  and  lateral  wall. 
In  case  of  complete  transverse  laceration  there  is  always  marked  re- 
traction, leaving  a  space  from  one-half  to  three-fourths  of  an  inch,  at 
first  filled  with  blood-clot,  later  converted  into  an  abscess. 

Symptoms. — The  symptoms  of  laceration  of  the  urethra  are  urethral 
hemorrhage,  the  immediate  formation  of  a  circumscribed  tumor  at  the 
seat  of  injury,  retention  of  urine,  and  pain. 


92  genito-ueijstaey  diseases  and  syphilis. 

The  amount  of  bleeding  from  the  urethra  cannot  be  regarded  as  an 
index  of  the  severity  of  the  lesion.  Blood  escaping  from  the  meatus 
after  trauma  always  indicates  laceration  of  the  mucous  membrane  at 
least,  and  even  though  but  a  small  quantity  is  lost,  as  in  the  breaking  of 
a  chordee  or  from  a  false  movement  in  coitus,  there  is  liable  to  result 
periurethral  inflammation,  with  the  ultimate  formation  of  an  unyield- 
ing stricture. 

The  immediate  perineal  swelling  is  due  to  extravasated  blood. 
Skin  discoloration  appears  after  one  or  two  days.  When  extravasa- 
tion of  infected  urine  takes  place  there  will  be  the  symptoms  of  deep 
cellulitis,  involving  the  scrotum  and  penis  and  extending  upward  over 
the  abdomen.  Retention  of  urine  is  observed  in  a  large  majority  of 
cases.  When  there  is  total  rupture  this  retention  is  due  to  separation 
of  the  urethral  ends  and  the  interposition  between  them  of  masses  of 
coagulated  blood.  In  cases  of  partial  rupture,  obstruction  of  the  tube 
from  blood-clot  and  urethral  spasm  incident  to  the  injury  may  be 
operative  in  causing  retention.  If  retention  is  not  at  first  noticed,  but. 
develops  subsequently,  it  is  due  to  obstruction  caused  by  inflamma- 
tory swelling. 

In  rupture  of  the  posterior  urethra  there  may  be  neither  bleeding 
from  the  meatus  nor  any  sign  of  perineal  tumor.  When  urinary 
extravasation  takes  place  it  occurs  in  the  deep  tissues,  and  produces 
no  symptoms  until  cellulitis  has  been  set  up.  In  cases  of  this  char- 
acter there  is  retention  of  urine  ;  obstruction  is  not  felt  on  introduc- 
tion of  the  catheter  until  it  has  penetrated  to  the  depth  of  six  inches 
and  is  passing  through  the  subpubic  urethra.  Then  either  its  further 
progress  is  arrested,  or  if  it  passes  into  the  bladder  and  remains  un- 
obstructed by  blood-clot  there  flows  urine  mixed  with  blood.  In 
ruptures  of  the  anterior  urethra,  when  the  bladder  is  once  reached 
by  instrumentation,  the  urine  is  clear. 

The  consequences  of  rupture  of  the  urethra  are  urinary  extrava- 
sation, septic  infection,  and  later  traumatic  stricture.  At  each  act  of 
micturition  a  part  or  the  whole  of  the  urine  is  liable  to  be  forced  into 
the  periurethral  cellular  tissue,  extending  at  once  into  the  scrotum  or 
the  perineum  if  the  fibrous  envelope  of  the  bulb  has  been  torn.  This 
urine,  even  if  originally  sterile,  shortly  becomes  infected,  sets  up  cellu- 
litis, and  occasions  sloughing  and  gangrene,  which,  unless  the  case  is 
promptly  attended  to,  result  in  death.  In  consequence  of  the  nature 
of  the  injury — i.e.,  a  crush — there  is,  when  the  canal  is  not  torn  com- 
pletely across,  more  or  less  sloughing,  with  subsequent  cicatricial 
contraction,  and  often  a  most  obstinate  fistula.  When  the  ruptured 
ends  of  the  urethra  have  not  been  apposed,  there  is  formed  between 


INJURIES   AND   DISEASES   OF    THE    URETHRA.  93 

them  a  granulating  sinus,  whose  walls  exhibit  all  the  vices  of  cica- 
tricial tissue.  Because  of  its  common  association  with  fractured  pel- 
yIs,  the  prognosis  of  rupture  of  the  membranous  urethra  is  guarded. 

Diagnosis. — The  history  of  the  injury,  the  perineal  tumor  of 
sudden  formation,  blopd  from  the  meatus,  either  flowing  spontane- 
ously or  induced  to  appear  by  pressure  on  the  perineal  tumor,  are 
sufficient  to  justify  an  absolute  diagnosis  of  rupture  of  the  anterior 
urethra.  Bleeding  is  in  itself  diagnostic  when  it  follows  trauma- 
tism, and  in  the  absence  of  perineal  tumor  and  marked  dysuria 
denotes  simply  a  slight  tear  of  the  mucous  membrane  without  involve- 
ment of  the  periurethral  tissues.  A  rapidly  formed  perineal  tumor 
associated  with  dysuria  or  retention  usually  signifies  an  extensive 
laceration.  The  seat  of  rupture  is  indicated  by  local  tenderness  and 
often  by  the  signs  of  external  violence.  The  history  of  the  injury  is 
also  of  importance  in  determining  this  point.  Thus,  when  there  has 
been  a  fall  astride  of  a  comparatively  wide  surface,  such  as  a  joist  or 
the  pommel  of  a  saddle,  the  bulbous  urethra  is  almost  certainly 
involved.  If  the  injury  has  resulted  from  a  fall  on  the  edge  of  a 
board,  for  instance,  it  is  probable  that  the  membranous  urethra  is  rup- 
tured. In  cases  of  pelvic  fracture  or  disjunction  the  diagnosis  is  some- 
times extremely  difficult.  There  is  little  deformity,  and  crepitus  may 
not  be  elicited.  There  may  be  bleeding  from  the  meatus,  but  usually 
the  spasm  of  the  compressor  urethrse  muscle  causes  the  blood  to  flow 
back  into  the  bladder.  The  history  of  the  injury, — commonly,  in  case 
of  fracture,  a  crushing  force  applied  to  the  two  sides  of  the  pelvis, — 
the  detection  of  crepitus  by  rectal  examination,  the  almost  invariable 
development  of  urinary  retention,  and  the  difficulty  in  catheterization 
or  the  drawing  off  from  the  bladder  of  blood  with  the  urine,  would 
point  to  rupture  of  the  membranous  urethra. 

Treatment. — In  the  least  serious  cases — i.e.,  those  characterized  hj 
moderate  hemorrhage  from  the  meatus,  either  with  or  without  circum- 
scribed non-progressive  tumor-formation  in  the  perineal  region,  and 
not  complicated  by  retention — the  use  of  pressure,  together  with  the 
application  of  hot  antiseptic  compresses,  the  administration  of  urinary 
antiseptics  by  the  mouth,  rest  in  bed,  free  purgation,  and  mild  anti- 
septic irrigation  of  the  urethra,  may  bring  about  cure.  In  the  simplest 
form  of  urethral  rupture  the  catheter  should  not  be  used  unless 
dysuria  or  retention  makes  it  necessary.  Under  these  circumstances 
a  large,  soft,  elbowed  gum  instrument  should  be  employed ;  and  it 
should  be  introduced  and  withdrawn  with  a  solution  of  protargol 
(1  to  2000)  flowing  through  it  from  a  fountain  syringe  elevated  not 
more  than  two  feet  above  the  bladder  level. 


94  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

In  case  symptoms  of  deep  inflammation  develop, — i.  e.,  increased 
swelling  and  tenderness,  with  constitutional  involvement, — recourse 
must  at  once  be  had  to  more  radical  means. 

In  the  severer  cases  of  rupture,  characterized  by  decided  perineal 
tumor,  urethral  bleeding,  and  urinary  retention,  if  the  soft  gum  or 
more  rigid  elbowed  catheter  can  be  passed  into  the  bladder  and  there 
flows  from  it  clear  urine,  this  instrument  may  be  allowed  to  remain  in 
place  for  three  to  five  days  (for  details  of  continuous  catheterization, 
see  page  312),  the  perineal  blood  effused  being  limited  by  the  immediate 
application  of  cold  and  pressure.  If  the  soft  catheter  cannot  be  made 
to  enter  the  bladder,  immediate  perineal  section  is  indicated.  Ad- 
visable when  there  is  retention  or  marked  dysuria  and  the  catheter 
cannot  be  passed  readily,  this  operation  becomes  absolutely  imperative 
when  oedematous  swelling  of  the  perineum  and  scrotum  and  symp- 
toms of  constitutional  depression  make  it  apparent  that  urinary  ex- 
travasation and  consequent  cellulitis  have  occurred. 

The  operation  is  conducted  in  accordance  with  the  principles  laid 
down  on  page  251.  A  catheter  or  staff  is  passed  to  the  seat  of  rupture, 
and  the  perineum  is  opened  upon  this  in  the  middle  line.  This  can  be 
done  under  eucaine  anaesthesia.  The  incision  should  be  free.  On  open- 
ing the  deep  layer  of  the  superficial  fascia  there  is  found  a  cavity  filled 
with  clots,  with,  in  recent  cases,  bleeding  still  persisting.  Guided  by 
the  catheter,  the  urethra  is  readily  identified,  threads  are  passed 
through  its  two  sides  to  act  as  retractors,  and,  in  case  the  canal  is  not 
completely  torn  across,  the  catheter  is  readily  passed  into  the  bladder. 
Bleeding  points  are  then  secured  by  ligature,  and  the  urethral  rent  is 
closed,  if  possible,  by  interrupted  chromicized  gut  suture,  including  in 
its  grip  as  much  periurethral  tissue  as  possible.  The  cavity  resulting 
from  the  bleeding  is  closed  by  buried  catgut  sutures  and  the  skin  is 
secured  by  silkworm-gut.  The  catheter  is  left  in  place  from  four  to 
six  days. 

If  the  urethra  is  completely  torn  across  and  the  proximal  urethral 
end  is  not  discovered  after  a  brief  but  careful  search,  Guyon  advises 
the  passage  of  a  sound  from  the  meatus  till  its  extremity  is  arrested 
by  the  posterior  wall  of  the  cavity  made  by  the  blood  extravasation. 
The  left  index  finger  is  then  passed,  palmar  side  up,  to  the  point 
pressed  upon  by  the  tip  of  the  sound.  The  latter  is  slightly  with- 
drawn, and  in  many  cases  just  above  the  position  occupied  by  the 
end  of  the  finger  will  be  found  the  proximal  end.  Through  it,  guided 
by  the  finger,  may  be  passed  an  instrument  from  the  perineum  into 
the  bladder.  Sudden  bimanual  pressure  on  the  bladder  by  the 
fingers  of  one  hand  in  the  rectum  and  of  the  Oihor  over  the  hypo- 


INJURIES   AND    DISEASES   OF    THE    URETHRA.  95 

gastric  region  may  cause  a  few  drops  of  urine  to  exude,  and  thus 
show  the  position  of  the  torn  mucous  channel,  which  in  recent  cases 
is  found  to  be  a  movable  bleeding  cord.  When  eucaine  anaesthesia 
has  been  employed,  the  patient  may  aid  the  surgeon  by  efforts  at 
micturition. 

When  the  case  has  advanced  to  abscess-formation  and  extensive 
sloughing,  or  when  the  rupture  has  occurred  as  a  complication  of 
pelvic  fracture,  it  may  be  impossible  to  find  the  proximal  end  of  the 
urethra  except  by  means  of  retrograde  catheterization  practised 
through  a  suprapubic  opening  made  in  the  bladder. 

The  proximal  end  of  the  urethra  having  been  found,  a  soft  rub- 
ber catheter  is  passed  from  the  meatus  into  the  bladder,  and  the 
ragged  or  irregular  wound  edges  are  trimmed  off,  and  approximated 
over  the  catheter  by  means  of  chromicized  catgut  sutures,  taking  in 
the  periurethral  tissues.  This  suture  is  made  easy  by  thrusting  the 
proximal  end  of  the  urethra  downward  and  forward  well  into  the 
wound  by  means  of  a  finger  inserted  into  the  rectum.  Often  union 
does  not  take  place  ;  but,  even  though  it  fails,  less  cicatricial  tissue  is 
formed  than  when  there  has  been  no  attempt  at  suture.  When  there 
is  no  local  infection  the  whole  wound  is  closed  by  buried  catgut  sutures, 
an  antiseptic  dressing  being  held  in  place  either  by  a  T-bandage  or  by 
a  crossed  of  the  perineum.  Continuous  catheterization  is  not  em- 
ployed for  more  than  six  days,  (See  page  252,)  After  the  catheter  is 
withdrawn  a  full-sized  sound  is  passed  every  three,  four,  or  five  days 
for  some  weeks,  and  is  afterwards  continued  at  longer  intervals  for 
months  or  years. 

Even  when  operation  is  delayed,  and  infiltration  and  septic  inflam- 
mation have  already  occurred,  approximation  of  the  torn  urethral 
ends  should  be  attempted  by  suture.  There  should,  however,  be  no 
effort  to  close  the  infected  cavity,  this  being  cleansed  and  packed  with 
sterile  or  iodoform  gauze  and  allowed  to  granulate  from  the  bottom. 

FOREIGN    BODIES   IN   THE   URETHRA. 

Foreign  bodies  in  the  urethra  are  either  introduced  from  without 
or  pass  forward  from  the  bladder,  in  the  latter  case  appearing  as 
urinary  calculi  or  fragments  of  neoplasm.  The  bodies  introduced 
from  without  are  usually  segments  of  catheter,  the  instruments  em- 
ployed being  old  and  breaking  during  introduction  or  withdrawal. 
In  the  case  of  social  perverts  almost  any  object,  if  sufficiently  small, 
may  be  passed  into  the  urethra.  Exceptionally,  animal  parasites  may 
be  found. 

The  behavior  of  a  foreign  body  lying  completely  within  the  urethra 


96  GENITO-URINAEY   DISEASES    AND   SYPHILIS. 

depends  upon  its  shape  and  size.  When  it  is  smooth  and  rounded,  as, 
for  instance,  in  the  case  of  a  broken  fragment  of  catheter,  a  small  wax 
candle,  or  a  piece  of  lead-pencil,  it  nearly  always  exhibits  a  tendency 
to  pass  back  into  the  bladder.  This  occurs  in  about  thirty  per  cent, 
of  all  cases,  and  is  due  to  the  constant  handling  of  the  parts  by  the 
patient,  to  the  frequent  erections  reflexly  excited  by  the  presence  of 
the  foreign  body,  followed  during  subsidence  by  contraction  of  the 
urethra  in  the  direction  of  its  length,  and  to  the  action  of  the  longitu- 
dinal unstriped  muscular  fibres  of  the  urethra.  A  smooth,  not  too 
large  foreign  body  may  pass  back  into  the  bladder  in  less  than  a  day. 

Should  the  foreign  body  remain  in  the  urethra,  the  navicular  fossa, 
the  bulb,  and  the  prostatic  urethra  are  its  seats  of  preference,  these 
portions  of  the  canal  representing  the  regions  of  greatest  dilatation. 

Symptoms. — Localized  pain,  interference  with  micturition,  and  in- 
flammatory phenomena  are  the  characteristic  symptoms  of  foreign 
body  in  the  urethra. 

The  pain  is  usually  severe,  especially  when  the  foreign  body  is 
irregular  in  shape.  When  a  catheter  is  broken  off  in  a  urethra  which 
has  long  been  tolerant  of  instrumentation,  there  may  be  no  suffering, 
especially  if  the  broken  end  is  lodged  in  the  membranous  or  prostatic 
portion.  Foreign  bodies  located  in  the  posterior  urethra,  particularly 
if  irregular  in  shape,  with  sharp  corners  or  angles,  cause  pain  charac- 
teristic of  posterior  urethritis, — i.e.,  there  is  a  deep  ache  felt  in  the 
perineum,  with  itching,  burning,  or  a  sense  of  weight  and  dragging  in 
the  rectum,  and  shooting  or  persistent  pain  in  the  hypogastric  region, 
about  the  sacro-iliac  articulation,  and  radiating  down  the  inner  sur- 
faces of  the  thighs. 

Interference  with  micturition  depends  mainly  upon  the  size  and 
position  of  the  foreign  body  and  upon  the  amount  of  inflammatory 
reaction  its  presence  sets  up.  Immediate  retention  is  rare.  There 
are  always  increased  frequency  of  urination  and  lessening  in  the  force 
and  volume  of  the  stream.  Unless  the  body  is  removed  or  passes 
back  into  the  bladder,  micturition  becomes  progressively  more  diffi- 
cult and  painful  because  of  swelling  due  to  inflammation. 

Inflammatory  phenomena  are  quickly  developed.  When  the  body 
is  lodged  in  the  anterior  urethra,  there  is  shortly  a  blood-stained  muco- 
purulent discharge,  with  redness,  heat,  and  swelling  of  the  penis. 
This  is  commonly  accompanied  by  fever.  When  the  body  is  lodged 
in  the  posterior  urethra,  increased  tenderness  on  perineal  and  rectal 
palpation,  the  appearance  of  constitutional  symptoms,  and  often  the 
development  of  cystitis  or  epididymitis,  show  extension  of  inflamma- 
tion. 


INJURIES    AND    DISEASES    OF    THE    URETHRA.  97 

Diagnosis. — The  history  of  the  case  is  usually  sufficient  to  estab- 
lish the  diagnosis.  In  the  case  of  a  sexual  pervert,  a  reliable  history 
may  be  entirely  wanting.  The  symptoms  in  themselves  are  merely 
suggestive,  since  pain,  frequent  and  obstructed  urination,  and  ure- 
thritis may  develop  from  a  variety  of  causes. 

Direct  examination,  even  in  the  absence  of  history,  nearly  always 
makes  the  nature  of  the  case  plain.  Palpation  will  usually  show  the 
size,  shape,  and  seat  of  the  body  if  it  is  located  in  the  anterior  urethra. 
Bimanual  palpation  is  employed  when  the  foreign  body  is  farther 
back,  the  fmger  of  one  hand  being  passed  into  the  rectum,  whilst 
with  the  other  counter-pressure  is  exerted  first  in  the  perineum,  then 
in  the  suprapubic  region. 

Providing  the  urethra  is  not  strictured,  the  urethroscope  can  always 
be  depended  upon  to  bring  the  foreign  body  into  view.  This  instru- 
ment also  enables  the  surgeon  to  determine  the  amount  of  impaction, 
and  to  choose  and  apply  his  extracting  instruments  so  that  they  shall 
act  to  the  greatest  mechanical  advantage.  In  introducing  the  urethro- 
scopic  tubes,  if  the  position  of  the  foreign  body  has  been  previously 
determined,  pressure  behind  it  should  be  made,  lest  by  manipulation 
it  should  be  forced  back  into  the  bladder. 

The  introduction  of  a  metal  sound  about  No.  18  F.  will,  in  the 
absence  of  the  urethroscope,  show  the  position  of  the  foreign  body  by 
the  resistance  which  is  encountered  when  it  is  reached,  and,  in  case 
the  body  be  hard,  by  the  chck  which  is  heard  when  it  is  touched.  In 
this  manipulation,  pressure  from  behind  should  be  employed  to  pre- 
vent the  body  from  being  pushed  into  the  bladder. 

A  foreign  body  introduced  into  the  urethra,  if  neither  expelled  nor 
extracted,  may  pass  back  into  the  bladder  or  may  remain,  becoming 
incrusted  with  urinary  salts  and  causing  ulceration  which  is  prone  to 
extend  through  the  urethral  wall,  forming  a  suppurating  cavity  which 
opening  externally  may  result  in  an  obstinate  urethral  fistula.  It 
is  in  the  prostatic  urethra  that  foreign  bodies  are  most  apt  to  remain 
indefinitely,  causing  slow  'ulceration,  and  becoming  so  embedded  in 
inflammatory  material  that  their  detection  maybe  extremely  difficult. 

A  foreign  body  once  lodged  within  the  urethra  if  not  expelled  with 
the  first  subsequent  act  of  micturition  is  not  likely  to  be  expelled  after- 
wards. Inflammatory  swelhng  fixes  it  more  firmly,  and  from  reflex 
irritation  causing  frequent  urination  the  stream  loses  in  volume  and 
force.     There  are,  however,  exceptions  to  this  rule. 

Treatment. — The  simplest  method  of  ridding  the  urethra  of  the 
foreign  body,  and  one  which  may  succeed  providing  the  case  be  seen 
immediately  after  its  introduction,  is  to  direct  the  patient  to  urinate 

7 


98 


GENITO-UEINARY   DISEASES    AND   SYPHILIS. 


forcibly.  When  the  stream  is  fairly  started  the  lips  of  the  meatus 
are  pressed  together  for  four  or  five  seconds  and  are  then  suddenly 
released.  This  failing,  recourse  should  be  had  at  once  to  forceps. 
(Fig.  51.)  The  introduction  of  these  is  preceded  by  examination 
through  the  urethroscope,  thus  enabling  the  surgeon  to  judge  how 
best  to  apply  them,  or  in  case  the  foreign  body  be  a  pin  or  a  splinter 
it  may  be  removed  directly  through  an  endoscopic  tube.  In  grasping 
the  body  with  forceps  it  should  be  pressed  forward  from  behind  by 
perineal  or  rectal  pressure,  thus  avoiding  the  danger  of  pushing  it 
back  into  the  bladder.  If  the  forceps  fail  to  grasp  the  body,  or  if 
because  of  its  angular  shape  withdrawal  requires  so  much  traction 
that  extensive  laceration  of  the  urethra  is  liable  to  result,  further 
attempts  at  extraction  should  be  abandoned,  the  patient  being  put 
in  the  lithotomy  position  and  the  body  being  removed  through  a 
perineal  or  penile  incision  carried  down  to  it  in  the  middle  hne. 

Fig.  51. 


Urethral  forceps. 


The  resulting  wound  is  closed  by  a  buried  catgut  suture  including 
the  urethra  and  its  fibrous  investment,  but  not  the  epithelial  layer 
of  the  mucous  membrane,  and  skin  stitches  of  silkworm-gut  or 
horse-hair. 

Special  manipulations  may  be  serviceable  in  certain  cases.  Thus, 
should  the  foreign  body  be  a  gum  catheter,  a  lead-pencil,  or  other 
non-metallic  body,  and  should  the  forceps  fail  to  grasp  it,  ordinary 
round-pointed  sewing  needles  may  be  driven  into  it  through  the 
urethra,  and  by  means  of  these,  the  elasticity  of  the  urethral  walls 
allowing  some  play  to  the  needles,  the  foreign  body  gradually  may 
be  brought  to  the  meatus. 

The  evacuating  tubes  employed  for  lithotomy,  or,  better  still,  a 
large,  straight  cyhnder,  open  at  the  end  and  attached  to  the  Bigelow 
evacuator,  may  prove  efficient  when  forceps  fail.  The  tube  is  carried 
down  to  the  foreign  body,  the  urethra  is  temporarily  obhterated  be- 
hind the  latter  by  firm  pressure,  its  anterior  part  is  then  distended  by 
sudden  pressure  upon  the  aspirating  bag,  and  this  pressure  is  imme- 


INJURIES   AND   DISEASES   OF   THE    URETHRA. 


99 


diately  relaxed.  The  foreign  body  may  thus  be  sucked  into  the 
evacuating  tube.  A  pin,  nearly  always  introduced  head  first,  may  be 
extracted  by  driving  its  point  through  the  urethral  walls,  thus  render- 
ing it  easy  to  seize  the  head  in  the  forceps  within  the  urethra. 

URETHRAL  CALCULI. 
Exceptionally  calculi  are  formed  within  the  urethra,  in  which  case 
they  are  always  phosphatic.  Usually  they  come  from  the  kidney  or 
the  bladder,  and,  though  apparently  phosphatic  from  incrustation, 
show  a  uric  acid  nucleus.  They  are  most  frequently  observed  in 
infancy  and  past  middle  age.  Their  common  seat  is  in  the  bulbo- 
membranous  and  prostatic  regions  and  in  the  navicular  fossa.  Cal- 
culi rarely  form  spontaneously  in  the  urethra  behind  a  stricture,  the 
stagnation  not  being  sufficient  to  allow  of  this.  It  is  in  urethral 
pouches  or  diverticula,  or  in  the  suppurating  bhnd  pouches  resulting 
from  glandular  inflammation  complicating  urethritis,  that  calculous 
formation  most  frequently  takes  place. 


Fig.  52. 


Urethral  calculi  showing  segmeutatiou. 

The  direction  of  growth  from  incrustation  of  the  calculi  found 
behind  strictures  or  in  physiologically  dilated  parts  of  the  urethra  is 
dependent  upon  the  pressure  exerted  by  the  urethral  walls.  The 
layers  of  lime  salt  are  so  deposited  as  a  result  of  this  pressure  that 
the  growth  is  backward.  As  the  calculi  increase  in  length  they  are 
liable  to  be  segmented  by  fracture :  hence  in  many  cases  several 
calculi  are  found  placed  in  line  and  articulating  with  one  another. 
(Fig.  52.)  Prostatic  calculi  growing  backward  encounter  much  pe- 
ripheral resistance  in  the  region  of  the  vesical  neck.  Having  passed 
this,  there  is  nothing  to  prevent  their  extension  in  all  directions. 
Hence  these  calculi  often  exhibit  the  appearance  of  two  nodules 
connected  by  a  narrow  bar.     (Fig.  53.) 

The  growing  calculus  may  cause  great  dilatation  of  the  infantile 
urethra.  In  the  adult  there  is  more  commonly  ulceration,  the  calcu- 
lus escaping  into  the  periurethral  tissues,  and  sometimes  in  this  posi- 


100 


GENITO-URINAKY    DISEASES   AND    SYPHILIS. 


tion  attaining  great  size  before  it  reaches  the  surfaces  or  causes  inflam- 
mation or  urinary  infiltration  sufficiently  serious  to  require  operation. 
Usually  the  ulcerating  cavities  in  which  these  calculi  lie  open  exter- 
nally. In  about  twenty  per  cent,  of  cases  urinary  infiltration  occurs. 
A  calculus  which  has  thus  left  the  urethra,  and  which  lies  in  a  cavity 
which  communicates  with  the  latter  only  by  a  narrow  opening,  cannot 
be  detected  by  the  passage  of  urethral  instruments. 

Symptoms — Calculi  which  form  in  the  urethra  would  give  no  other 


Fig.  53. 


Urethral  calculi  showing  mushroom  shape.    Cross-sections  to  exhibit  lamination. 

symptoms  than  those  due  to  the  inflammation  and  gradually  increas- 
ing obstruction, — i.e.,  urethral  discharge  and  increased  frequency  of 
urination  followed  by  dysuria.  Impacted  calculi  from  above  occur  in 
the  persons  of  those  who  have  passed  gravel  or  have  had  attacks  of 
nephritic  colic.  In  children  these  symptoms  are  generally  absent. 
The  lodgement  of  the  stone  occurs  during  urination.  There  is 
sudden  partial  or  complete  stoppage  of  the  stream,  with  the  sensa- 
tion of  a  solid  body  having  lodged  in  the  urethra.  This  is  followed 
by  the  symptoms  of  foreign  body  in  the  urethra.  (See  page  96.) 
Diagnosis. — Given  the  sudden  stoppage  of  the  stream  during  uri- 


INJUKIES  AND   DISEASES   OF   THE   UKETHEA.  IQI 

nation  and  the  sensation  of  a  foreign  body  having  shpped  into  the 
urethra,  with  a  precedent  lithasmic  history,  the  diagnosis  is  reason- 
ably certain.  It  is  further  confirmed  by  palpation  of  the  urethra, 
which  may  show  a  hard  body,  but  more  commonly  elicits  only 
localized  tenderness,  and  by  the  use  of  the  urethroscope,  which 
in  the  absence  of  stricture  makes  the  diagnosis  absolutely  certain, 
and  also  shows  the  seat  of  lodgement.  In  the  absence  of  the  urethro- 
scope the  soft  woven  catheter  or  bougie  should  be  employed  ;  this  in 
striking  the  stone  produces  a  rough  grating  sensation.  When  there 
is  stricture  the  small  metal  sound  is  passed,  the  click  then  showing  the 
position  and  nature  of  the  obstruction,  or,  this  failing,  rectal  examina- 
tion may  enable  the  stone  to  be  felt  lying  between  the  finger  and 
the  sound.  Stones  lying  in  diverticula  or  in  periurethral  abscesses 
can  usually  be  detected  only  by  palpation. 

The  consequences  of  the  impaction  of  stone  in  the  urethra  are 
not  often  serious.  In  cases  of  stricture  with  damaged  kidneys,  com- 
plete retention,  if  not  promptly  relieved,  may  have  disastrous  conse- 
quences. The  symptoms  of  impaction  are,  however,*  so  marked  that 
treatment  is  promptly  instituted :  hence  there  is  little  chance  for 
grave  systemic  disturbances.  Stones  which  have  ulcerated  through 
the  urethral  walls  always  expose  the  patient  to  the  danger  of  urinary 
infiltration. 

Treatment. — The  treatment  is  practically  the  same  as  that  directed 
in  the  case  of  foreign  bodies.  Immediate  removal  of  the  stone  is  the 
prominent  indication.  If  it  is  situated  at  or  near  the  navicular  fossa, 
meatotomy  may  be  required.  The  straight,  open-ended  evacuating 
tube  may  render  valuable  service.  CalcuH  in  the  prostato-mem- 
branous  urethra  which  cannot  be  grasped  readily  by  the  forceps,  or 
which,  if  grasped  and  drawn  upon,  show  such  resistance  that  extensive 
laceration  of  the  urethra  is  certain  to  occur,  should  be  pushed  into  the 
bladder  by  a  bougie,  and  then  crushed  and  evacuated.  If  this  pushing 
back  into  the  bladder  requires  force,  they  should  be  cut  down  upon 
and  removed,  the  urethra  and  wound  being  closed  by  buried  sutures* 
Calculi  in  any  part  of  the  urethra  which  are  firmly  embedded  should 
be  treated  in  the  same  way.  When  the  calculus  lies  behind  a  stricture, 
this  should  be  divided  by  internal  urethrotomy  if  it  lies  anterior  to  the 
bulb,  by  external  urethrotomy  if  it  is  bulbo-membranous,  the  stone 
then  being  removed  either  through  the  meatus  by  forceps  or  through 
the  perineal  wound.  Stones  lying  in  extra-urethral  abscesses  should 
be  removed  by  incision,  the  opening  into  the  urethra  being  freshened 
and  closed  by  catgut  sutures  and  the  abscess-cavity  being  drained  by 
packing. 


CHAPTER    III. 

AFFECTIONS    CHARACTERIZED    BY    URETHRAL    DISCHARGE. 

In  accordance  with  their  etiology,  affections  characterized  by  ure- 
thral discharge  may  be  classified  as  follows : 

1.  Urethrorrhoea.     Entirely  independent  of  local  lesions. 

2.  Traumatic  urethritis,  due  to  {a)  Instrumentation.  (6)  Irritating 
injections,  (c)  External  traumatism. 

3.  Irritative  urethritis.  («)  Ingestive,  due  to  certain  drugs  and  articles 
of  food  ;  (6)  Diathetic,  dependent  upon  u-ritating  conditions  of  the  urine 
incident  to  defective  metabolism  ;  gouty,  rheumatic,  oxaluric,  and  phos- 
phaturic  urethritis  ;  (e)  Erethismic,  due  to  repeated  excessive  coitus  or 
prolonged  ungratifled  sexual  excitement. 

4.  Eruptive  urethritis  occurs  during  the  course  of  certain  acute 
exanthemata  ;  and  as  a  manifestation  of  urethral  herpes  or  eczema. 

5.  Mechanical  urethritis,  incident  to  (a)  Stricture,  (6)  Urethral 
neoplasms,  (c)  The  lodging  of  urinary  calculi,  {d)  Rarely,  in  children, 
the  entrance  of  animal  parasites. 

6.  Concomitant  urethritis,  dependent  upon  disease  of  para-  and 
periurethral  structures. 

7.  Infective  urethritis.— («)  Simple  pyogenic,  sometimes  called  irri- 
tative or  abortive  gonorrhoea  ;  (6)  Gonococcal ;  [c)  Syphilitic  (primary, 
secondary,  tertiary) ;  {d)  Chancroidal ;  ie)  Tuberculous  ;  (/)  Typhoidal ; 
{g)  Influenzal ;  Qi)  Pneumococcic  ;  (i)  Diphtheritic. 

Urethrorrhoea  is  due  solely  to  depraved  constitutional  conditions, 
and  occurs  mdependently  of  local  lesions.  It  is  observed  during  con- 
valescence from  acute,  exhausting  diseases,  such  as  typhoid  fever,  scarlet 
fever,  pneumonia,  influenza,  small-pox,  and  the  like  ;  or  in  the  course 
of  such  chronic  affections  as  tuberculosis,  cancer,  syphilis,  advanced 
nephritis,  neurasthenia,  anaemia,  and  other  debilitating  cachectic  con- 
ditions. The  discharge  is  dependent  upon  a  relaxed  and  leaky 
mucous  membrane,  and  represents  an  excessive  quantity  of  what  is 
in  character  a  normal  secretion.  This  constitutes  the  sole  symptom, 
appearing  as  a  colorless  viscid  material  not  unlike  glycerin.  In  the 
urine  it  forms  long  shreds. 

Diagnosis.— This  depends  on  the  history,  the  general  physical 
102 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.    103 

examination,  and  the  elimination  of  other  causes,  such  as  catheteriza- 
tion, etc.  Microscopic  examination  of  the  discharge  shows  mucus, 
epithelial  cells,  a  few  leucocytes,  and  a  variety  of  bacteria  normally 
present.     Spermatozoa  are  often  found. 

Treatment  should  be  entirely  constitutional.  Incidentally,  the  urine 
should  be  kept  unirritating.  Local  congestion,  such  as  would  be  caused 
by  sexual  excitement,  stripping  the  urethra,  and  irritating  injections 
must  be  avoided.     Internally,  cubebs  may  be  serviceable. 

URETHRITIS. 

Etiology. — The  predisposing  cause  of  urethritis  is  congestion.  Ihis 
may  be  incident  to  constitutional  or  to  local  conditions.  Both  often 
act  together. 

The  exciting  cause  of  urethritis  is  microbic  infection.  This  may 
be  existent  in  a  healthy  urethra,  producing  symptoms  only  when 
favoring  conditions  are  present ;  may  be  introduced  from  without ; 
may  reach  the  urethra  from  involved  peri-  and  para-urethral  struct- 
ures or  by  elimination  through  the  kidneys. 

The  gonococcus  may  cause  urethritis  in  the  absence  of  predis- 
posing congestion,  though  the  latter  greatly  favor.s  its  development. 
This  form  of  infection,  much  exceeding  in  frequency  and  importance 
all  others  combined,  will  be  discussed,  together  with  its  complications, 
in  a  separate  section. 

Pathology. — This  is  similar  to  that  of  inflammation  of  other  mucous 
canals,  with  certain  differences  incident  to  the  anatomy  and  physiology 
of  the  urethra,  its  susceptibility  to  certain  varieties  of  microbic  invasion, 
and  its  accessibility  to  local  treatment. 

The  inflammation  common  to  all  forms  of  the  acute  disease  usually 
begins  at  or  near  the  meatus  and  spreads  backward.  The  mucosa  of 
the  canal  and  of  its  many  follicles  and  lacunae  becomes  infiltrated,  red, 
swollen,  covered  with  a  mucoid,  sanious,  or  purulent  exudate,  and  soon 
the  epithelium  exfoliates.  In  the  milder  cases  the  process  is  limited  to 
the  mucosa,  and  after  a  few  days  or  weeks  subsides,  but  exceptionally, 
the  inflammation  may  persist  in  the  follicles  and  glands  for  weeks  and 
months. 

In  severe  cases  the  infective  agents  penetrate  deeply  into  the  sub- 
mucous tissue,  causing  abundant  round-cell  infiltration,  nests  of  which 
may  be  the  beginning  of  periurethral  abscess.  The  process  may  involve 
any  or  all  of  the  structures  opening  into  the  urethra,  including  the  upper 
urinary  tract.  Lymphangitis  and  lymphadenitis  are  common,  phlebitis 
and  cellulitis  are  rare. 

Urethroscopic  examination  of  acute  diffuse  urethritis  shows  red- 


104  GEXITO-URIXAEY   DISEASES   Al^B   SYPHILIS. 

ness,  swelling,  and  exfoliation  of  the  mucous  membrane,  and  muco- 
purulent exudation. 

Symptomatology. — Discharge  is  the  only  constant  symptom.  With 
this  are  commonly  associated  the  usual  symptoms  of  inflammation. 

Pain  may  vary  from  the  slightest  itching,  tickling,  or  burning  sen- 
sation at  the  meatus  to  constant  harassing  distress  throughout  the 
whole  of  the  canal.  It  may  be  referred  to  the  glans,  the  penis,  the 
deep  perineum,  or  may  radiate  down  the  thighs. 

Alterations  of  function  vary  from  slightly  frequent  urination  to 
annoying  urgency,  associated  with  painful  vesical  and  rectal  tenesmus. 
Tenderness  is  manifested  by  burning  upon  urination,  aching  during 
erection,  or  a  stabbing,  cutting  anguish  during  seminal  emission.  Per- 
sistent, painful  erections,  with  nocturnal  pollutions,  and  chordee,  may 
occur ;  rarely  acute  retention  develops  from  reflex  or  voluntary  inhibi- 
tion of  the  detrusors  or  contraction  of  the  sphincter.  The  objective 
signs  may  be  absent ;  they  may  appear  as  a  simple  florid  puffiness  of 
the  lips  of  the  meatus,  or  may  be  conspicuous  in  the  form  of  inflamma- 
tory oedema  of  the  glans,  the  prepuce,  and  rarely  the  subcutaneous 
tissue  with  accompanying  bubo. 

The  mechanical  disturbances  dependent  on  the  swelling  vary  ;  there 
may  be  slight  difficulty  in  starting  the  stream,  loss  of  force  or  diminution 
of  the  normal  paraboHc  curve,  or  dribbling  after  the  act.  Swelling  or 
gluing  of  the  lips  of  the  meatus  may  break  or  deflect  the  stream. 

The  discharge  may  be  manifest  only  in  the  urine  ;  it  may  appear  as 
a  slight  moisture  at  the  meatus,  not  noticed  unless  the  intervals  between 
urination  are  long,  or  as  a  drop  after  stripping  the  urethra,  or  during  a 
straining  effort  at  defecation.  In  acute  cases  it  may  appear  as  a  pro- 
fuse, continuous  outpour. 

In  character,  it  may  be  thin  and  watery,  viscid,  gelatinous,  and 
stringy,  resembling  the  uncooked  white  of  e^^,  milk-and-watery  in 
appearance,  or  may  be  made  up  of  a  thick,  yehowish,  greenish  san- 
guino-purulent  material.  It  may  be  noted  in  the  form  of  crusts  where 
it  has  dried  around  the  meatus,  or  as  stains  on  the  underclothing.  It 
may  be  without  odor,  or  extremely  foul. 

The  urine  may  be  cloudy,  or  quite  opaque,  depending  on  the 
amount  of  mucus,  pus,  and  blood  contained  in  it ;  or  may  exhibit 
various  forms  of  urethral  shreds,  from  the  irregular,  short,  thick, 
scaly,  tack,  or  comma-shaped  particles,  to  long,  translucent,  branching, 
gelatinous  threads. 

Traumatic  urethritis  is  usually  due  to  instrumentation  or  to 
irritating  injections.     It  may  be  caused  by  external  traumatism. 

Instrumentation  always  causes  more  or  less  traumatism,  varying  in 


AFFECTIONS  CHAKACTERIZED  BY  URETHRAL  DISCHARGE.     105 

degree  from  slight  contusion  to  laceration,  puncture,  or  even  rupture 
of  the  urethra. 

Irritating  injections,  usually  of  strong  mercuric  chloride  or  carbolic 
acid  or  silver  nitrate  solution,  are  commonly  used  to  prevent  or  abort 
gonorrhoea. 

The-  symptoms  are  commensurate  to  the  severity  of  the  trauma. 
Those  of  the  hyperacute  type  developing  immediately  and  characterized 
by  great  pain,  rapid  swelling,  agonizing  ardor  urinae,  or  even  retention 
of  urine  and  a  scanty  discharge  of  bloody  pus  are  practically  always 
due  to  irritating  injections.  Prolonged  or  brutal  catheterization  may 
cause  an  intense,  frankly  purulent  inflammation,  but  of  comparatively 
slow  development. 

External  traumatism  can  produce  urethritis  only  by  first  causing 
a  sanguineous  effusion  into  the  urethra  and  in  the  periurethral  tis- 
sues as  a  result  of  partial  or  complete  rupture  of  the  canal.  (See 
page  91.) 

Prognosis. — Urethritis  due  to  irritating  injections  is  at  times  dis- 
tressingly persistent,  and  may  lead  ultimately  to  stricture  formation. 
Generally  the  symptoms  disappear  promptly. 

Treatment. — Instrumentation  urethritis  may  be  best  avoided  by  the 
skilful  use  of  clean  instruments,  preceded  by  cleansing  the  glans  and 
by  antiseptic  urethral  flushings.  For  the  avoidance  of  the  urethritis 
incident  to  continuous  catheterization,  see  page  315.  During' the  acute 
course  of  an  injection  urethritis,  in  addition  to  rest  in  bed,  hot  sitz- 
baths,  diluents  by  the  mouth,  and  opium  suppositories,  urethral  injec- 
tions of  eucaine  and  adrenalin  together  with  evaporating  lotions  applied 
to  the  penis  may  be  needed  to  relieve  retention  of  urine  due  to  inflam- 
matory swelling..  Urethritis  from  external  traumatism  should  be 
treated  by  irrigation  and  sound. 

Irritative  Urethritis. — Under  this  heading  are  included  Ingestive, 
Diathetic,  and  Erethismic  Urethritis. 

Ingestive  urethritis,  characterized  by  scanty  mucoid  discharge  and 
slight  ardor  urinse,  is  occasionally  noted  after  the  ingestion  of  such 
substances  as  asparagus,'  rhubarb,  turpentine,  cubebs,  copaiba,  can- 
tharides,  alcohol,  arsenic,  and  potassium  iodide. 

Diagnosis. — This  is  based  on  the  history,  and  on  the  absence  of 
other  causes  for  urethral  discharge.  The  symptoms  are  mild,  the 
duration  of  the  affection  brief,  and  cure  results  at  once  upon  removal 
of  the  cause.  Ardor  urinae  may  be  more  marked  than  the  inflamma- 
tory symptoms  would  seem  to  warrant.  The  discharge  which  follows 
the  abuse  of  alcohol  is  not  strictly  ingestive,  but  is  usually  due  to  the 
lighting  up  of  a  latent  lesion  by  the  irritating  condition  of  the  urine 


106  ge:n^ito-urinapvY  diseases  and  syphilis. 

When  the  symptoms  are  unduly  prolonged,  a  search  should  be  made 
for  such  lesions. 

Diathetic  urethritis  is  dependent  upon  the  irritating  urine  inci- 
dent to  gout,  rheumatism,  and  the  defective  metabolism  characterized 
by  the  habitual  appearance  of  large  quantities  of  oxalates  and  phos- 
phates in  the  urine.  The  relation  between  the  joint  manifestations  of 
rheumatism  and  gout  and  a  slight  mucoid  urethral  discharge  has 
been  repeatedly  noted ;  indeed,  this  discharge  has  been  observed  occa- 
sionally as  a  manifestation  of  so-called  retrocedent  gout. 

Diagnosis. — This  must  be  based  on  the  history.  The  discharge  is 
associated  with  general  diatetic  errors  rather  than  with  the  ingestion  of 
one  or  two  particular  articles  of  food.  Other  manifestations  of  gout  or 
rheumatism  are  present  and  the  acid  urine  is  highly  concentrated. 
The  discharge  is  mucoid  in  character,  with  an  abundance  of  epithelial 
cells,  a  few  leucocytes,  and  no  gonoccoci.  (For  the  differential  diagnosis 
between  gonorrhoeal  arthritis  and  gouty  or  rheumatic  urethritis,  see 
page  200. J 

Prognosis. — In  the  absence  of  complicating  gonorrhoeal  lesions,  the 
urethral  catarrh  disappears  Avhen  the  constitutional  condition  is  bet- 
tered and  the  urine  rendered  bland. 

Treatment  is  obvious.  Local  treatment  is  not  indicated.  If,  how- 
ever, the  discharge  persists,  search  should  be  made  for  localized 
lesions. 

Oxaluria  and  phosptiaturia  of  themselves  rarely  cause  urethral 
discharge,  though  they  make  quite  incurable  one  which  was  originally 
started  as  a  gonorrhoeal  infection.  The  persistence  of  oxalates  or 
phosphates  in  the  urine,  accompanied  by  a  mucoid  or  muco-purulent 
discharge  neither  gonococcal  nor  tubercular  in  nature  and  unassoci- 
ated  with  urethral  stricture,  polyp,  or  other  localized  lesion,  would 
justify  the  suspicion  that  the  discharge  is  dependent  on  the  pathologic 
condition  of  the  urine. 

Erethismic  Urethritis. — The  discharge  resulting  from  sexual  ex- 
cesses or  prolonged  ungratified  sexual  excitement  is  mucoid  in  char- 
acter. It  may  be  exceedingly  persistent  and  usually  indicates  a 
urethra  especially  susceptible  to  bacterial  infection. 

Treatment. — This  is  mainly  systemic.  Bromides  are  very  excep- 
tionally of  service.  Hyoscine  hydrobromate,  grain  yto,  twice  daily,  is 
useful  Avhen  the  discharge  is  due  to  prolonged  ungratified  sexual  ex- 
citement. For  this  condition  the  psychrophore  (see  page  790)  is  also 
serviceable  at  times.  As  a  rule,  local  treatment  is  contraindicated. 
Exercise,  hydrotherapy,  occupation,  and  diet  usually  suffice  to  effect 
a  cure. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.    107 

Eruptive  urethritis  is  often  overlooked.  It  is  due  to  an  active 
hyperaemia,  with  perhaps  an  accompanying  eruption  on  the  mucous 
membrane.  Doubtless  the  irritating  condition  of  the  urine  is  a  con- 
tributing factor.  The  appearance  of  slight  urethral  discharge  coinci- 
dent with  the  development  of  the  skin  or  mucous  membrane  lesions 
of  the  fever,  the  elimination  of  other  sufficient  causes  for  such  a  dis- 
charge, and  the  disappearance  of  the  latter  with  the  betterment  of  the 
constitutional  condition,  would  sufficiently  indicate  the  diagnosis.  No 
local  treatment  is  needed. 

Herpetic  urethritis  is  characterized  by  a  sudden,  apparently 
causeless,  slight  discharge  commonly  accompanied  by  severe  neu- 
ralgic or  burning  pain  greatly  exaggerated  during  micturition,  pre- 
ceded, followed  by,  or  alternating  with  external  herpetic  lesions. 
There  are  no  gonococci  and  no  involvement  of  the  posterior 
urethra. 

Mechanical  Urethritis. — A  persistent  urethral  discharge  in  a 
healthy  man,  whose  urine  is  normal  and  who  leads  a  fairly  healthful 
life,  should  always  suggest  the  likelihood  of  a  localized  urethral  lesion, 
and  should  lead  to  an  examination  for  stricture,  ulcer,  chronic  folliculi- 
tis, or  urethral  polyp.  If  the  discharge  has  been  preceded  by  a  sud- 
den complete  or  partial  stoppage  of  the  urine  in  the  absence  of  a  his- 
tory of  previous  urethral  inflammation  the  lodgement  of  a  calculus 
should  be  suspected.     (Seepage  100.) 

Cancer  of  the  Urethra. — Primary  cancer  of  the  urethra  occurs  in 
men  over  fifty  years  of  age  who  have  suft'ered  from  chronic  urethritis 
due  to  stricture.  It  has  been  found  only  in  the  bulbous  and  mem- 
branous urethra.  The  growth  invariably  proceeds  towards  the  penis 
(Hall),  showing  no  tendency  to  invade  the  prostate  and  the  tissues 
behind  the  triangular  ligament. 

Symptoms. — The  symptoms,  during  the  early  stage  of  infiltration, 
are  simply  those  of  chronic  urethritis  ;  later  there  may  be  increasing 
difficulty  in  urinating,  obstruction  to  the  passage  of  a  catheter,  and  the 
formation  of  rapidly  growing  infiltrations,  which,  in  the  absence  of 
previously  existing  fistula,  soften  in  one  or  more  spots  and  rupture, 
discharging  pus,  blood,  and  often  very  offensive  urine.  After  rupture 
there  is  found  a  comparatively  small  cavity  with  hard,  irregular  walls 
tending  to  furtgate  in  places. 

Diagnosis. — The  diagnosis  is  based  upon  the  dense  infiltration,  the 
progressive  and  rapid  growth,  and  the  removal  and  microscopical 
examination  of  a  portion  of  the  tumor.  The  tendency  to  bleed  and 
fungate  and  enlargement  of  the  inguinal  lymphatics  may  possibly  prove 
of  diagnostic  value. 


108  GENITO-UEINAEY  DISEASES   AND   SYPHILIS. 

Cancer  of  Cowper's  gland,  which  on  first  examination  may  suggest 
primary  cancer  of  the  urethra,  may  be  distinguished  from  the  latter 
by  the  fact  that  it  has  at  first  a  tendency  to  grow  towards  the  skin  and 
rectum  rather  than  in  the  direction  of  the  urethra,  forming  a  palpable 
perineal  tumor,  which,  till  it  has  reached  a  large  size,  does  not  inter- 
fere with  the  passage  of  a  catheter  or  the  free  flow  of  the  urine. 

In  cancer  of  the  urethra  the  prognosis  is  absolutely  bad,  since 
diagnosis  is  never  made  till  the  disease  is  well  advanced.  The  dura- 
tion of  life  from  the  time  diagnosis  is  established  is  rarely  more  than 
six  months. 

Treatment. — Immediate  and  complete  removal  of  all  the  diseased 
parts  and  of  the  anatomically  associated  glands  is  indicated.  Where 
this  is  not  possible,  irrigations,  local  washings,  and  morphine  in  suffi- 
cient doses  to  quiet  the  patient  should  be  employed. 

Concomitant  Urethritis.— The  peri-  and  para-urethral  affec- 
tions causative  of  urethral  discharge  include :  Folliculitis,  Cowperitis^ 
Prostatitis,  Vasitis,  Seminal  vesiculitis  and  Cystitis. 

The  usual  cause  of  the  extra  urethral  affections  which  keep  up  the 
discharge  is  gonorrhoea.  The  history  will  ordinarily  show  this  to  have 
been  present.  Before  its  continuance  can  be  eliminated,  it  will  be 
necessary  to  make  frequently  repeated,  painstaking  examinations  of 
the  urethral  discharge,  the  urine,  and  the  semen  for  gonococci,  micro- 
scopically (by  the  Gram  method)  and  sometimes  culturally.  When 
there  is  no  history  of  gonorrhoea,  persistent  urethral  discharge  second- 
ary to  infection  of  the  prostate,  seminal  vesicles,  vas,  or  bladder  should 
lead  to  careful  examination  for  tuberculosis. 

Even  though  a  urethral  discharge  be  found  associated  with  an 
extra  urethral  affection,  its  dependence  upon  the  latter  cannot  be  as- 
sumed till  all  other  causative  factors,  and  particularly  stricture-forma- 
tion, have  been  eliminated,  since  the  usual  cause  of  persistent  urethral 
discharge  is  stricture. 

Specific  Urethritis. — Simple  purulent  inflammation  develops 
after  unclean  sexual  intercourse  or  unclean  instrumentation,  particu- 
larly in  those  who  from  sexual  excess,  alcoholic  indulgence  or  previ- 
ous attacks  of  urethritis  are  especially  vulnerable.  The  exciting  cause 
may  be  any  form  of  pyogenic  organism. 

Symptoms. — These  vary  greatly.  For  the  mild  cases  the  following 
is  descriptive  :  The  usual  cause  is  coitus  with  a  woman  suffering  from 
leucorrhoea.  It  is  characterized  by  a  varying  period  of  incubation,  usu- 
ally very  short,  at  most  one  or  two  days,  by  a  reddened,  swollen 
itching  meatus,  by  some  pain  on  urination,  and  by  a  milky  secre- 
tion from  the  urethra,  appearing  only  when  this  canal  is  stripped 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     109 

forward.  These  symptoms  are,  of  course,  identical  with  those  of 
the  earliest  stage  of  acute  gonorrhoea,  and,  except  by  microscopical 
examination  of  the  discharge,  this  form  of  disease  cannot  be  dis- 
tinguished from  true  gonorrhoea.  Its  course,  however,  is  differ- 
ent. Unless  the  inflammation  is  treated  by  irritants,  the  symptoms 
do  not  increase  in  severity.  Neither  ardor  urinas  nor  chordee 
develops.  The  discharge  continues  for  five  to  ten  days  and  then 
ceases  spontaneously.  There  are  no  sequelae  and  no  complications. 
The  condition  is  a  purely  catarrhal  one.  It  is  these  cases  which  have 
obtained  for  certain  remedies  a  repute  for  aborting  acute  gonorrhoea. 
The  disease  subsides,  under  almost  any  treatment  which  is  not  too 
violent,  in  a  time  which  is  very  short  as  compared  with  the  du'ration 
of  ordinary  gonorrhoea.  The  attendant  is  often,  and  not  unnaturally, 
led  to  believe  that  such  subsidence  is  due  rather  to  his  treatment  than 
to  the  spontaneous  cessation  of  the  disorder. 

The  account  just  given  represents  the  usual  course  of  a  simple 
Infectious  urethritis.  Exceptionally  the  inflammation  is  as  violent  and 
prolonged  as  if  from  gonococcus  infection.  In  strumous  and  cachectic 
individuals  the  discharge  may  remain  slight,  but  persists  for  weeks, 
months,  or  years,  in  spite  of  treatment,  and  commonly  brings  about 
a  marked  condition  of  sexual  neurasthenia. 

GoNORRH(EAL  URETHRITIS. — TMs  the  commouest  and  most  compli- 
cated variety  of  urethritis  is  considered  in  a  separate  section.  (See 
page  113.) 

Syphilitic  Urethritis. — A  urethral  discharge  may  be  due  to 
primary,  secondary  or  tertiary  syphilis.  Urethral  chancre,  usually 
placed  within  half  an  inch  of  the  meatus,  is  practically  never  recognized 
as  such  till  a  secondary  general  eruption  has  clearly  indicated  the 
nature  of  the  affection ;  yet  in  the  absence  of  a  mixed  infection  the 
diagnosis  should  be  suggested  by  a  urethral  discharge,  with  an  incuba- 
tion period  longer  than  ten  days,  induration,  inflammatory  infiltration 
of  the  fraenum,  the  detection  of  urethral  ulcer  covered  by  a  grayish 
pseudo-membrane,  and  bilateral,  non-inflammatory,  polyganglionic, 
inguinal  lymphadenitis. 

The  symptoms  of  urethral  chancre  may  be  limited  to  a  slight  pain- 
less muco-purulent  discharge,  spontaneously  disappearing  in  one  or 
two  weeks  ;  when  such  symptoms  are  detected,  especially  if  they  have 
followed  exposure  by  an  interval  greater  than  ten  days,  the  possibility 
that  they  have  been  caused  by  a  urethral  chancre  should  be  carefully 
considered. 

Urethral  chancre  must  be  distinguished  from  gonorrhoea,  from  sim- 
ple urethritis,  from  chancroid,  and  from  mucous  patches  of  the  urethra. 


110 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


From  gonorrhcea  the  urethral  chancre  can  be  differentiated  by  a 
consideration  of  the  contrasted  characteristics  of  each : 


Urethral  Chancre. 

Incubation. — Ten  days  to  three  weeks. 
Seat. — At  or  near  the  meatus. 

Urethroscopic  Appearance. — An  erosion 
or  ulceration,— a  circumscribed  area 
of  congested  mucous  membrane.  A 
healthy  urethra  behind  the  lesion. 

Symptohis. — Slight  ardor  urinse,  felt  only 
at  or  near  the  meatus.  Painful  erec- 
tions mostly  absent.  No  pain.  Gen- 
erally marked  oedema  about  the  frse- 
num. 

Discharge.  —  Scanty,  mucous,  blood- 
stained.    Contains  no  gonococci. 

Induration. — Distinct,  somewhat  diffuse, 
often  involves  one  lip  of  the  meatus. 


Sequelce. — Painless,  non -inflammatory 
enlargement  of  inguinal  lymphatics, 
followed  in  six  or  eight  weeks  by 
secondary  symptoms.  Spontaneous 
subsidence  of  local  symptoms. 

Sensibility. — ^The  application  of  a  syringe 
or  any  mechanical  interference  occa- 
sions pain  at  or  near  the  meatus. 


(jronorrhoia. 

Incubation. — One  to  seven  days. 

Seat. — ^The  entire  anterior  urethra.  Usu- 
ally invades  the  posterior  urethra. 

Urethroscopic  Appearance. — Marked  vas- 
cular engorgement  of  the  entire 
urethral  mucous  membrane,  often 
with  many  areas  of  epithelial  exfo- 
liation. 

Symptoms. — Ardor  urinae  marked,  and 
felt  along  the  course  of  the  urethra. 
Painful  erections  mostly  present. 
Often  pain.  Sometimes  marked  pre- 
putial oedema. 

Discharge.  —  Profuse,  muco-purulent. 
Usually  not  blood-stained.  Contains 
gonococci. 

Induration. — Absent.  At  times  a  hard, 
round  follicle  felt  beneath  the  urethra, 
which  either  suppurates,  discharging 
externally,  or  evacuates  its  contents 
into  the  urethra  and  quickly  subsides. 

Sequelce. — Lymphatics  do  not  enlarge, 
or  exceptionally  one  or  two  become 
acutely  inflamed,  and  sometimes  sup- 
purate. 

Sensibility. — ^The  use  of  a  long-nozzled 
syringe  or  any  mechanical  interfer- 
ence occasions  pain  along  the  course 
of  the  urethra. 


The  diagnosis  between  urethral  chancre  and  chancroid  must  be 
made  upon  the  grounds  which  enable  the  surgeon  to  distinguish  be- 
tween these  two  lesions  when  situated  upon  the  surfaces  of  the 
genitalia.  The  absence  of  a  period  of  incubation,  the  acute  local 
inflammatory  symptoms,  the  free  discharge,  and,  above  all,  the 
punched-out,  ragged,  non-indurated,  spreading  ulcer,  are  fairly 
characteristic  of  chancroid,  but  the  meatus  chancre  is  often  distinctly 
chancroidal  in  type. 

The  diagnosis  of  urethral  chancre  from  mucous  patches  of 
the  urethra  is  usually  made  easy  by  the  presence  of  other  mani- 
festations of  secondary  syphilis  and  the  absence  of  an  indurated 
ulceration   or  abrasion.     The   lesions  are  not  different  from   those 


AFFECTIONS  CHAKACTERIZED  BY  URETHRAL  DISCHARGE,     m 

observed  on  other  mucous  membranes.  The  disease  is  highly 
contagious. 

A  persistent  mucoid  or  muco-purulent  discharge  also  characterizes 
secondary  and  tertiary  syphilitic  lesions,  which  are  found  in  the  urethra 
as  areas  of  congestion,  mucous  patches,  or  relapsing  gummatous  ulcera- 
tions. Unless  there  be  a  double  infection  the  gonococci  will  not  be 
found.  Secondary  lesions  in  the  urethra  will  be  attended  by  co-exist- 
ing eruptions  on  other  mucous  surfaces  and  on  the  skin,  with  other  signs 
of  secondary  syphilis.  Urethroscopic  examination  will  show  areas  of 
non-indurated  exfoliation,  erosion,  or  ulceration,  usually  near  the 
meatus.  The  inflammatory  symptoms  are  mild  as  compared  to  gonor- 
rhoea!, herpetic,  and  eczematous  eruptions  ;  and  in  the  pure  syphihtic 
infection  there  are  no  symptoms  referable  to  the  posterior  urethra. 

Treatment. — This  is  that  appropriate  to  the  syphilis.  Injections  are 
rarely  needed. 

CuANCRomAL  URETHRITIS  begins  at  the  meatus  and  extends  back- 
ward. The  period  of  incubation  is  variable  (one  to  four  days  or 
longer).  Abundant  staphylococci  and  other  pyogenic  organisms  are 
found  in  the  purulent,  often  blood-stained,  secretions,  but,  unless  double 
infection  has  occurred,  no  gonococci ;  not  infrequently  similar  lesions 
are  noted  on  other  parts  of  the  genital  organs.  Absence  of  induration 
is  the  rule.     Inguinal  buboes  are  common. 

The  subjective  symptoms  are  mild  compared  with  the  profuseness 
of  the  discharge.  In  the  absence  of  mixed  infection  there  are  no  deep- 
seated  complications.  Unlike  chancre,  which  may  be  entirely  intra- 
urethral,  the  ulceration  of  chancroid  either  develops  on  the  lips  of  the 
meatus  or  shortly  appears  there,  making  the  detection  of  their  pres- 
ence easy.  Urethral  chancroids  are  occasionally  followed  by  fistulae, 
and,  as  a  rule,  by  stricture,  unless  this  be  guarded  against  in  the  course 
of  healing. 

Treatment. — This  is  conducted  in  accordance  with  the  principles 
laid  down  in  the  treatment  of  chancroid.  (See  page  50.)  Stricture  must 
be  guarded  against  by  the  use  of  a  meatus  bougie  during  the  process 
of  healing. 

Tubercular  Urethritis. — Tubercular  lesions  of  the  urethra  are 
extremely  rare.  When  observed,  they  are  usually  part  of  a  general 
uro-genital  tuberculosis,  the  prostate,  seminal  vesicles,  testicles,  blad- 
der, and  exceptionally  the  ureters,  exhibiting  tubercular  lesions.  Gen- 
erally the  lungs  are  also  invaded. 

Since  the  infection  is  usually  descending  and  is  carried  by  the 
urine,  its  manifestations  are  found  in  the  areas  of  physiological  dilata- 
tion, where  the  urine  is  most  subject  to  delay, — i.e.,  in  the  prostatic, 


112  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

bulbar,  and  navicular  portions  of  the  urethra.  The  prostatic  urethra 
alone  is  affected  in  the  great  majority  of  cases.  Exceptionally  lesions 
are  found  along  the  entire  urethra,  even  extending  to  the  surface  of 
the  glans  penis. 

These  lesions  may  appear  in  the  form  of  diffuse  or  clustered  miliary 
tubercles,  indolent  ulcers,  or  cheesy  infiltrations  presenting  a  diphthe- 
roid surface.  The  ulcerating  lesion  may  lead  to  stricture,  as  in  one 
case  reported  by  Ahrens. 

Urethral  locahzation  of  tubercular  lesions  is  favored  by  gonorrhoea 
or  by  any  form  of  inflammation  which  lessens  tissue  resistance  and 
breaks  the  surface  of  healthy  epithelium.  Primary  tuberculosis  in 
this  region,  by  direct  infection  from  without,  or  by  localization  of  the 
bacilH  present  in  the  blood,  is  practically  unknown.  The  clinical 
symptoms  of  a  general  infection,  however,  may  appear  first  in  the 
genito-urinary  tract. 

Symptoms. — The  symptoms  of  urethral  tuberculosis  are  a  chronic 
urethral  discharge,  and,  when  the  disease  affects  the  posterior  urethra, 
frequency  of  urination,  tenesmus,  pain,  and  often  blood  at  the  end  of 
urination.  Lesions  of  the  anterior  urethra  usually  excite  no  symp- 
toms other  than  a  slight  muco-purulent  discharge.  Injection  of  silver 
nitrate  ordinarily  occasions  a  violent  reaction. 

Diagnosis. — The  diagnosis  of  urethral  tuberculosis  is  founded  on 
the  discovery  of  the  tubercle  bacillus,  the  association  of  the  lesions 
with  evidence  of  tubercular  infection  in  other  parts  of  the  body,  par- 
ticularly in  the  genital  tract  and  in  the  lungs,  and  urethroscopic 
examination.  An  apparently  causeless  purulent  urethral  discharge 
should  always  suggest  a  careful  search  for  tubercle  bacilli. 

Treatment — The  treatment  is  dependent  upon  the  extent  and  mul- 
tiplicity of  lesions  other  than  those  found  in  the  urethra.  When  the 
urethral  infiltration  is  simply  a  part  of  a  general  infection,  irrigation, 
and  instillation  of  bichloride  solution  1  to  6000  once  daily,  and  the  use 
of  iodoform  bougies  ten  per  cent,  in  cacao  butter  or  gelatin,  or  of  iodo- 
form insufflated  through  the  tube  of  an  endoscope,  represent  as  active 
local  treatment  as  is  serviceable.  A  single  or  limited  infiltration 
should,  in  the  absence  of  lesions  elsewhere,  be  thoroughly  curetted 
or  removed  by  an  external  urethrotomy,  the  urethra  being  resected 
and  subsequently  sutured  should  complete  removal  require  this. 

Typhoidal  Urethritis. — The  urethral  inflammation  sometimes  ac- 
companying typhoid  fever  is  probably  dependent  upon  congestion  in- 
duced by  the  concentrated  febrile  urine,  which  in  turn  favors  infection 
by  the  Bacillus  coli  communis  and  other  pyogenic  bacteria.  The  dis- 
charge is  muco-purulent  in  character,  rarely  profuse,  contains  abundant 


AFFECTIONS  CHAEACTEEIZED  BY  URETHEAL  DISOBAEGE.    II3: 

pyogenic  bacilli,  pus-cells,  mucus,  and  epithelium  without  gonococci. 
There  is  always  accompanying  cystitis. 

Prognosis. — During  or  immediately  following  the  appearance  of 
typhoidal  urethritis,  but  generally  later  in  the  course  of  the  fever,  there 
may  develop  epididymo-orchitis.  The  latter,  however,  is  generally  a 
pure  typhoid  infection  occurring  through  the  blood.  (See  page  654.)  The 
urethral  discharge  promptly  disappears  as  convalescence  progresses. 

Treatment. — The  urine  should  be  rendered  bland.  Urinary  anti- 
septics are  indicated. 

Influenzal  urethritis  is  also  due  to  pyogenic  infection,  and  its 
relation  to  influenza  is  coincident. 

Pneumococcic  and  diphtheritic  urethritis  are  more  truly  specific, 
since,  in  these  forms  the  specific  bacteria  may  be  abundant  and  there 
is  (in  the  diphtheritic)  membrane  formation. 

Symjitoms. — These  are  severe,  the  discharge  profuse,  purulent,  and 
blood-stained.  There  may  be  shreds  of  membrane  exfoliated.  Con- 
stitutional symptoms,  fever,  etc.,  coexist.  Yet  rarely  does  the  process 
extend  further  than  the  anterior  urethra.  The  pneumococcic  is  far  less 
severe  than  the  diphtheritic. 

Diagnosis  depends  on  the  bacteriologic  examination,  since  false 
membranes  may  form  in  other  varieties  of  severe  urethritis. 

Prognosis  is  favorable,  the  disease  being  usually  short  in  duration. 

Treatment  should  be  constitutional  and  local.  Antitoxin  should  be 
employed  against  diphtheria.  Locally,  mild  antiseptic  irrigations  are 
indicated. 

GONORRHCEA. 

Gonorrhoea  is  a  contagious  specific  inflammation  of  the  mucous 
membranes  of  the  genito-urinary  tract.  It  also  affects  the  conjunc- 
tiva, the  rectum,  and  possibly  the  mucous  membranes  of  the  nose 
and  mouth.  It  is  alleged  that  it  can  attack  all  the  mucous  membranes, 
but  evidence  upon  this  point  is  far  from  conclusive. 

Etiology. — Gonorrhoea  depends  for  its  development  upon  the  pres- 
ence of  a  specific  microbe  termed  the  gonococcus.  While  it  is  true 
that  gonorrhoea  usually  runs  a  somewhat  typical  course, — one  much 
longer  and  attended  with  more  complications  than  when  the  inflam- 
mation is  due  to  traumatism,  or  irritation,  or  infection  with  the  ordi- 
nary microbes  of  suppuration, — this  is  by  no  means  invariably  the 
case.  Even  the  form  of  urethritis  excited  by  an  irritating  injection 
may  exceptionally  last  for  weeks  and  months,  and  may  be  attended 
by  every  complication  that  can  possibly  develop  during  the  course  of 
an  acute  gonorrhoea. 

8 


114  GENITO-URINAKY   DISEASES    AND   SYPHILIS. 

The  gonococcus  when  cultivated  under  favorable  circumstances 
on  a  suitable  medium  shovv^s  a  very  small,  scarcely  perceptible  gray- 
ish surface,  appearing  shiny,  moist,  and  slightly  yellovvrish  by  reflected 
light.  The  development  of  this  culture  is  slow,  and  the  growth  never 
extends  widely,  reaching  its  uttermost  dimensions  in  two  or  three 
days,  after  which  time  the  germs  lose  their  virulence,  and  shortly 
can  no  longer  be  transplanted  with  successful  results.  This  growth 
is  always  on  the  surface.  Baumgarten  states  that  in  twenty-four 
hours  its  extent  is  not  more  than  one  to  one  and  a  half  millimetres. 
It  is  inhibited  by  extremely  weak  antiseptic  solutions. 

Gonococci  grow  best  at  a  temperature  of  34°  to  37°  C,  and  human 
blood-serum  is  the  culture  medium  of  choice.  Even  in  this  medium, 
however,  pure  cultures  are  obtained  with  difficulty,  since,  because  of 
the  slow  growth  of  the  gonococcus,  its  culture  is  interfered  with  by 
the  rapid  proliferation  of  other  pyogenic  organisms. 

Torro  asserts  that  the  difficulty  in  cultivating  the  gonococcus  lies 
in  the  fact  that  alkaline  media  have  been  employed.  In  acid  urine 
the  gonococcus  develops  rapidly ;  this  suggested  to  him  the  idea  that 
acidity  is  a  requisite  in  all  media.  He  employed  ordinary  nutrient 
gelatin  without  neutralizing,  and  obtained  growths  of  the  germ.  He 
also  asserts  that  he  has  reproduced  the  disease  from  pure  cultures 
obtained  by  inoculating  dogs.  The  cultures  kept  in  acid  media  retain 
their  virulence  for  many  weeks,  whilst  those  transplanted  to  alkaline 
media  quickly  become  inert. 

It  must  be  remembered  that,  even  under  favorable  circumstances 
and  on  the  most  approved  media,  pure  cultures  of  the  gonococcus 
cannot  always  be  obtained.  Pus  swarming  with  apparently  virulent 
organisms  may  be  placed  on  proper  media  without  growth. 

The  gonococcus  is  distinguished  by  its  shape,  grouping,  position, 
color  reaction,  and  growth  on  artificial  media. 

In  shape  the  gonococci  resemble  the  two  seeds  of  a  coffee-bean, — 
that  is,  they  are  diplococci,  flat  or  slightly  concave  on  one  side,  and 
rounded  on  the  other,  with  their  flat  (Figs.  54-57)  surfaces  apposed. 
It  must  be  remembered  that  only  by  careful  staining  and  by  the  use  of 
high  power  can  these  micro-organisms  be  seen  as  diplococci.  The  two 
half-spheres  are  separated  by  such  a  very  narrow  interval  that  this  is 
not  perceived  by  the  use  of  the  ordinary  one-fourth  or  one-eighth  lens. 
In  the  process  of  multiplication  each  half  of  the  diplococcus  divides 
at  right  angles  to  the  fissure  between  the  two.  Hence  the  gonococci 
are  always  grouped  in  irregularly  shaped  colonies  ;  chains  are  never 
found.  They  quickly  take  the  stain  of  ordinary  basic  staining  reagents, 
such  as  fuchsin,  methyl  or  gentian  violet,  or  methylene  blue,  and  are 


Fici,  54. 


i9 


W    ^J 


'Xm:^  i'< 


'^* 


.^' 


J>/ 


4"- 


Acute  gonorrhoea. 


Acute  pyogenic  urethritis. 


Fig.  56. 


1 


^.-•:. 


i«&^ 


«8U 


'^'"'.. 

#„•: 


.5D 


<*   *   .i     *'" 


<^-   ?; 


^* 


{••I 


Chronic  gonorrhoea. 


Fig.  57. 


fi«»te' 


v^y 


Urinary  shred. 


AFFECTIONS  CHAKACTEKIZED  BY  TJKETHEAL  DISCHARGE.     J 1 5 

readily  decolorized  by  the  Gram  method,  this  fact  serving  to  distin- 
guish them  from  other  urethral  cocci. 

The  diagnosis  of  gonorrhoea  depends  upon  the  discovery  of  the  gono- 
coccus.  To  this  end  the  following  office  method  if  properly  applied 
is  usually  efficient,  and  is  applicable  to  all  varieties  of  urethral  dis- 
charge. 

Ptcagents  needed : — 

1.  The  anilin  water  staining  solution  of  Fraenkel-Ehrlich,  made  as 
follows  :  To  one  hundred  cubic  centimetres  of  two  per  cent,  solution 
of  carbolic  acid  in  distilled  water  add  about  five  cubic  centimetres  of 
anilin  oil,  drop  by  drop,  shaking  after  each  addition,  until  the  fluid 
remains  opaque  after  having  been  shaken.  Filter  through  moist  filter- 
paper,  and  add  to  the  clear  resultant  solution,  alcohol  ten  cubic  cen- 
timeters, and  saturated  alcoholic  solution  of  gentian  violet,  fuchsin,  or 
methylene  blue,  eleven  cubic  centimetres. 

2.  Gram's  solution  : 

Iodine,  1  part  ; 
Potassium  iodide,  2  parts  ; 
Water,  300  parts. 

3.  If  counter-staining  is  desired,  saturated  solution  of  Bismarck 
brown  in  two  per  cent,  carbolized  water  may  be  employed. 

4.  Ninety-five  per  cent,  alcohol. 

Technique  :  The  patient  should  not  have  voided  urine,  nor  used 
any  form  of  local  urethral  injection  for  a  length  of  time  (variable  with 
the  amount  of  discharge)  before  the  examination  is  to  be  made.  The 
region  about  the  meatus  should  be  gently  cleansed  with  a  pledget  of 
cotton  moistened  with  alcohol  to  avoid  bacteria  from  this  source. 
The  urethra  may  then  be  stripped,  so  that  a  small  drop  of  pus  may 
appear  at  the  meatus.  A  perfectly  clean,  clear,  thin  cover-glass  is 
then  touched  lightly  to  the  discharge  at  the  meatus,  so  that  a  fraction 
of  a  drop  will  adhere.  This  readily  occurs  in  all  purulent  discharges ; 
if  the  discharge  is.  pure  mucus,  the  glass  may  have  to  be  washed  with 
ether.  A  second  cover-glass  is  then  made  to  press  gently  on  the 
drop,  and  is  drawn  off  horizontally,  so  as  to  make  an  even  spread  on 
both  cover-glasses.  Both  smears  are  allowed  to  dry  in  the  air.  Each 
one  is  then  passed  slowly  three  tunes  through  the  flame  of  an  alcohol- 
lamp  or  Bunsen  burner,  to  fix  the  albumin,  care  being  taken  not  to 
burn  the  specimen.  One  of  the  preparations  is  then  held  film  side 
up  (preferably  in  a  pair  of  spring  forceps)  and  a  few  drops  of  the 
gentian-violet  staining  solution  dropped  upon  it.  This  is  allowed  to 
remain   from   two   to   five  minutes.     The  staining  process  may  be 


116  GENITG-URINARY   DISEASES   AND   SYPHILIS. 

hastened  by  heating.  The  excess  of  solution  is  then  gently  washed 
off,  the  preparation  blotted  between  folds  of  filter-paper,  mounted  in 
balsam,  and  examined  with  one-twelfth  oil  immersion  lens.  If  no 
cocci  of  any  kind  are  found,  the  examination  need  go  no  further. 
Commonly,  however,  a  great  many  cocci  are  seen,  bearing  close  re-r 
semblance  to  the  shape,  size,  and  arrangement  of  gonococci,  if  not 
identical  in  morphological  characteristics.  These,  together  with  the 
epithelial  cells,  leucocytes,  bacilli,  and  other  structures  in  the  smear, 
are  stained  deep  blue  or  violet,  depending  on  which  stain  is  used.  In 
such  a  case  the  Gram  method  must  be  employed  in  order  to  differ- 
entiate the  organisms. 

If  in  ordinary  acute  urethritis  the  clinical  symptoms  are  clearly 
those  of  gonorrhoea,  the  above  may  be  omitted  and  the  following 
process  carried  out  in  the  beginning.  It  may  be  done  after  a  little 
practice  in  a  few  minutes. 

1.  Take  the  second  smear  which  has  been  dried  and  fixed,  cover 
with  the  anilin-water-gentian-violet  staining  solution,  and  allow  to 
remain  two  to  five  minutes. 

2.  Shake  off  the  excess  of  stain.  Do  not  use  water  or  alcohol  to 
wash  it  off. 

3.  Immerse  in  Gram's  solution  for  one  to  three  minutes.  In  this 
solution  the  preparation  becomes  nearly  black. 

4.  Wash  in  ninety-five  per  cent,  alcohol  until  all  the  violet  color 
has  disappeared, — i.e.,  until  the  specimen  appears  colorless  or  has  only 
a  steel  gray  tint. 

5.  The  alcohol  is  now  washed  away  with  water,  the  smear  dried 
between  filter-paper,  and  mounted  in  balsam. 

In  this  specimen  the  gonococci  and  epithelial  and  pus-cells  may  be 
seen  unstained  ;  all  other  organisms  will  be  stained  purple  or  violet. 

A  more  beautiful  specimen,  one  less  trying  to  the  eyes  and  in 
which  the  gonococci  are  more  easily  seen,  may  be  made  by  counter- 
staining  the  specimen  with  the  Bismarck  brown.  The  latter  stain 
may  be  applied  after  washing  off  the  alcohol  with  water  and  allowed 
to  remain  two  to  three  minutes.  The  preparation  is  then  finally 
washed  with  water,  blotted,  and  mounted.  In  this  case  the  cells  and 
gonococci  will  be  easily  seen  of  a  yellowish-brown  color,  in  contrast  to 
the  deep  purple  of  the  other  organisms. 

If  with  this  method  there  are  discovered  in  urethral  pus  the  char- 
acteristic biscuit-shaped  diplococci,  arranged  in  jsairs,  fours,  and  other 
multiples  of  two,  showing  a  tendency  to  rectangular  disposition^  and 
located  within  the  cellular  elements,  the  diagnosis  of  gonorrhoeal 
urethritis  is  sufficiently  positive  for  all  clinical  purposes.     If,  however. 


AFFECTIONS  CHARACTEKIZED  BY  UKETHKAL  DISCHARGE.    .117 

negative  resttlts  are  obtained, — i.e.,  if  gonococci  are  not  found, — we 
cannot  be  absolutely  sure  the  patient  has  not  gonorrhoea. 

In  medico-legal  cases  or  in  cases  involving  a  question  of  chastity 
or-  of  family  relations,  repeated  examinations  may  be  required  and 
the  concurrent  circumstances  should  be  given  full  weight  in  reaching 
a  conclusion. 

Failure  to  fmd  the  organisms  may  be  incident  to  faulty  technique 
or  to  imperfectly  prepared  reagents.  The  organisms  may  be  so  deeply 
situated  in  the  submucous  tissue  or  the  paraurethral  glands  that  they 
are  found  in  the  discharge  only  w^hen  it  has  been  aggravated.  Hence 
it  is  helpful  to  make  the  examination  the  morning  after  a  night  of  dis- 
sipation or  a  dinner  of  highly  irritating  food,  or  a  horseback  or  bicycle 
ride,  or  to  set  up  a  more  or  less  acute  superficial  inflammation  by  in- 
strumentation or  irritating  injection,  or  to  examine  the  discharge  ex- 
pressed by  massage  of  the  prostate,  seminal  vesicles,  and  Cowper's 
glands.  Moreover,  there  are  certain  other  cocci  (the  micrococcus 
catarrhalis  and  diplococcus  intra-cellularis  meningitidis)  which  also  are 
negative  to  Gram,  but  these  organisms  are  not  found  in  the  urethra. 

Microscopic  examination  will  note  in  the  mucoid  discharge  varying 
relative  quantities  of  mucus,  flat  and  columnar  epithelium  and  fibrin, 
together  with  a  few  leucocytes,  some  normally  existing  non-virulent 
bacteria,  and  perhaps  a  few  spermatozoa.  In  the  purulent  exudations, 
in  addition  to  these  elements,  will  be  found  myriads  of  pus-cells, 
various  pathogenic  bacteria,  and  in  some  cases  blood-cells. 

The  mucoid  discharge  occurs  throughout  the  entire  course  of  the 
disease  only  in  urethorrhoea.  The  muco-purulent  discharge  is  char- 
acteristic of  the  early  and  late  stages  of  gonorrhoea  and  of  the  entire 
course  of  all  the  other  varieties  of  urethritis  except  when  they  develop 
in  hyperacute  form. 

The  purulent  discharge  is  particularly  characteristic  of  gonorrhoea. 
It  is  noted  in  other  forms  of  urethritis  when  the  infection  is  unusually 
severe. 

Urethral  shreds  are  of  the  same  mucoid,  muco-purulent,  or  puru- 
lent character.  In  general  the  mucoid  shreds  are  light  and  float  near 
the  surface  of  the  urine,  tlie  purulent  ones  sink  in  the  fluid,  and  the 
muco-purulent  occupy  a  middle  position  in  the  glass  after  the  urine  has 
been  allowed  to  stand. 

In  examining  the  shreds  microscopically  they  are  taken  from  the 
urine  by  means  of  a  platinum  loop,  pipette,  or  small  forceps,  placed 
on  the  slide,  the  excess  of  water  absorbed  by  blotting  paper,  and  the 
specimen  stained  in  exactly  the  same  way  as  in  the  discharge  from  the 
meatus.     The  pus-cells  are  shrunken,  degenerated,  and  fragmented 


118  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

from  resorption  of  water.  The  gonococci  are  never  so  abundant,  and 
require  for  their  demonstration  more  technical  skill. 

In  the  mucoid  discharge  there  are  a  few  bacteria  scattered  between 
the  cells,  in  the  muco-purulent  they  are  abundant  and  in  groups,  and 
in  the  purulent  discharge  they  exist  in  myriads,  apparently  both  within 
and  without  the  cells,  in  chains  and  clumps. 

The  position  of  the  gonococci  is  exceedingly  characteristic.  They 
are  always  found  heaped  in  the  protoplasm  of  the  pus  and  epithelial 
cells.     At  times  the  cells  appear  entirely  filled  with  these  organisms. 

The  number  of  gonococci  in  acute  typical  gonorrhoea  is  very  con- 
siderable ;  though  there  may  be  an  admixture  of  other  micro-organ- 
isms, these  latter  are  distinctly  in  the  minority.  At  the  very  begin- 
ning of  an  acute  attack,  or  in  its  terminal  stages,  there  may  be  very 
few  gonococci.  It  is  here  only  that  Roux's  test  is  valuable,  since 
the  shape,  grouping,  and  number  in  the  midcourse  of  an  acute  attack 
are  absolutely  characteristic. 

The  important  characteristics  of  gonococci  may  be  summarized  as 
follows:  they  are  diplococci ;  they  appear  in  heaps,  which  nearly 
always  occupy  the  protoplasm  of  cells ;  they  are  very  numerous  in 
acute  cases ;  they  are  readily  colored  by  aniline  dyes  and  decolorized 
by  Gram's  solution  and  alcohol ;  they  form  characteristic  pure  cultures 
on  suitable  media  (acid) ;  and  are  non-pathogenic  to  lower  animals. 

Source  of  the  Discharge. — If  from  the  anterior  urethra,  it  appears 
at  the  meatus  either  spontaneously  or  after  stripping.  If  from  the 
posterior  urethra,  it  is  noted  just  before  urination  or  during  the 
passage  of  hard  feces,  or  after  thorough  irrigation  of  the  anterior 
urethra  in  the  second  or  third  beaker  in  the  three-glass  test.  If  from 
the  prostate  and  seminal  vesicles,  it  appears  after  milking  these  glands, 
If  from  the  bladder,  it  is  noted  at  the  end  of  micturition.  Origin  from 
combined  sources  is  common. 

Pathology. — The  gonococci,  having  been  deposited  on  the  surface 
of  the  mucous  membrane,  multiply  rapidly  and  penetrate  the  epi- 
thelium, shortly  reaching  its  deepest  layers,  but  stopping  abruptly  at 
the  subepithelial  connective  tissue. 

In  twenty-four  hours  after  this  invasion  of  the  deeper  epithelial 
layers  there  is  an  active  migration  of  leucocytes,  separating  the  epithe- 
lial cells,  and  often  causing  exfoliation,  usually  of  those  lying  super- 
ficially, at  times  of  complete  layers.  Regeneration  follows  very  quickly, 
particularly  in  young  men.  According  to  Bumm  and  Baumgarten, 
only  mucous  surfaces  provided  with  cylindrical  epithelium  or  epithe- 
lium transformed  into  this  variety  are  subject  to  infection.  Thus  they 
explain  the  immunity  of  the  buccal  and  part  of  the  nasal  mucous 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.    119 

membrane  and  of  the  vagina  of  adults.  This  is  also  interesting  in 
reference  to  the  method  of  spontaneous  cure  of  gonorrhoea,  since 
where  the  micro-organisms  most  deeply  invade  the  tissues  there  is 
formed  during  the  process  of  healing  a  many-layered,  horny,  flat  epi- 
thelium. The  anatomical  alterations  consist  in  reddening,  swelling, 
and  free  discharge,  first  of  thin  fluid,  later  of  thick  pus  often  mingled 
w4th  blood.  The  mucous  membrane  shows  erosions,  and,  very  excep- 
tionally, distinct  ulcers.  The  crypts,  follicles,  and  gland-ducts  become 
swollen,  often  blocked  with  pus-plugs,  and  form  sacs  containing  pus 
and  degenerated  epithelium. 

Clinically,  gonorrhoea  may  be  acute,  subacute,  or  chronic,  and  each 
of  these  forms  may  have  its  lesions  more  intensely  marked  in  either 
the  anterior  or  the  posterior  urethra. 

Typical  Acute  Gonorrhoea  of  the  Male  Urethra. — This  form 
of  urethral  inflammation  is  due  to  infection  of  the  urethra  with  the 
gonococcus.  Such  infection  is  nearly  alv^^ays  due  to  sexual  inter- 
course, the  virulent  pus  from  the  female  entering  the  male  urethra  to 
a  greater  or  less  depth.  This  method  of  acquiring  the  disease  is 
termed  immediate  contagion. 

The  disease  also  may  be  conveyed  by  mediate  contagion, — that  is, 
through  the  medium  of  clothing  or  other  articles  containing  specific 
micro-organisms.  Since  to  excite  inflammation  the  micro-organism 
must  gain  access  to  the  urethra,  it  can  readily  be  seen  that  mediate 
contagion,  excepting  by  the  agency  of  bodies  introduced  within  the 
urethra,  must  be  exceedingly  rare. 

Incubation. — There  is  always  an  interval  of  time  between  expo- 
sure to  contagion  and  the  development  of  noticeable  urethral  symp- 
toms. During  this  time  the  germs  are  multiplying,  and  a  focus  of 
inflammation  is  becoming  established  sufficiently  extensive  and  in- 
tense to  excite  attention.  This  time  varies  between  a  few  hours  and 
two  or  three  weeks,  since  it  depends  upon  the  original  strength  of  the 
microbic  invasion,  the  seat  of  entrance,  and  the  vital  resistance  of  the 
mucous  membrane.  An  extremely  short  incubation  period  or  one 
which  is  unusually  long  should  always  lead  the  surgeon  to  doubt  the 
gonorrhoeal  nature  of  the  urethritis  till  this  is  determined  by  micro- 
scopic examination.  Three  to  five  days  represent  the  ordinary  incu- 
bation period, — that  is,  the  time  elapsing  between  exposure  to  the 
disease  and  the  development  of  the  first  symptom. 

Prodromal  Symptoms. — Often  the  first  symptom  of  a  developing 
urethritis  is  a  constantly  recurring  tendency  to  fix  the  attention  on  the 
penis.  Even  though  the  parts  seem  perfectly  normal,  there  is  a  strong 
desire  to  subject  them  to  frequent  inspection. 


120  GENITO-XJElISrAKY   DISEASES   AND   SYPHILIS. 

A  sense  of  heat  and  itching  in  the  glans,  shght  fugitive  tickling 
sensations  at  the  meatus,  together  with  a  feehng  of  weight  and  tension 
in  the  penis  arid  a  tendency  to  develop  erection  on  the  slightest  exeite- 
ment,  are  most  frequently  noticed. 

Inflammatory  Symptoms. — In  twenty-four  hours  symptoms  of  in- 
flammation become  more  pronounced:  there  are  now-developed  (1) 
swelling  of  the  meatus  and  (2)  discharge,  becoming  more  and  more 
marked  from  day  to  day,  and  shortly  supplemented  by  (3)  ardor 
urinse  and  (4)  chordee  ;  later  by  (5)  frequent  urination  and  vesical 
tenesmus. 

Inflammatory  Swelling. — 1,  The  lips  of  the  meatus  are  swollen  and 
oedematous,  often  everted,  or  even  eroded.  At  times  the  swelling  is 
so  great  that  the  urine  can  be  passed  only  in  a  slow  stream.  Usually 
the  stream  is  forked  and  irregular. 

In  severe  cases  the  glans  becomes  gorged  with  blood,  and  the  fore- 
skin may  be  swollen,  reddened,  and  oedematous.  Enlarged  lymphatic 
vessels  may  be  felt  passing  as  hard  cords  from  the  frsenum  to  the  back 
of  the  penis. 

The  urethra  swells  and  becomes  tender  on  pressure.  It  is  at 
times  nodular,  owing  to  involvement  of  the  glands  and  folhcles. 

2.  The  discharge,  at  first  scanty  and  of  milk-and-water  color,  turns 
to  a  greepish  yellow,  and  is  frequently  mixed  with  blood  from  the  con- 
gested mucous  membrane.  It  varies  in  quantity  in  accordance  with 
the  extent  and  violence  of  the  inflammation,  increasing  till  the  disease 
has  reached  its  acme. 

In  the  first  stage  of  the  disease  the  discharge  is  thin,  gray-white^ 
and  made  up  of  mucus  and  of  pavement  epithelial  cells,  with  a  very 
small  amount  of  pus.  Gonococci  are  usually  free  ;  some  groups  are 
found  in  the  epithelial  cells.  As  the  disease  increases  in  intensity 
the  epithehal  ceHs  and  the  mucus  give  place  to  pus-cells  and  the  gono- 
cocci become  very  abundant ;  the  discharge  is  thick,  yellow,  greenish, 
or  distinctly  blood-stained,  and  very  profuse.  As  the  disease  passes 
into  the  stage  of  decline  the  pus-cells  are  less  abundant,  and  the  dis- 
charge lessens,  becomes  milk-and-watery  in  color  and  contains  much 
mucus,  and  shows  on  examination  many  flat  transitional  epithelial 
cells.  Finally,  the  pus  entirely  disappears,  usually  leaving  for  days 
or  weeks  an  oversecretion  of  mucus,  which  appears  in  the  urine  as 
long,  irregular,  translucent  shreds. 

However  profuse  the  discharge  of  posterior  urethritis,  it  never 
passes  forward,  this  being  prevented  by  the  tonic  contraction  of  the 
compressor  urethras  muscle. 

When   gonorrhoea!   inflammation   involves  the  posterior   urethra. 


AFFECTIONS  CHARACTEKIZED  BY  URETHRAL  DISCHARGE.    121 

without  occasioning  symptoms  it  can  be  detected  only  by  an  examina- 
tion of  the  urine,  wliich  wih  be  found  to  be  far  more  cloudy  than  can 
be  accounted  for  by  the  very  slight  anterior  discharge.  The  existence 
of  inflammation  of  the  posterior  urethra  may  be  still  further  confirmed 
by  causing  the  patient  to  pass  his  water  in  two  portions.  The  first 
part  will,  of  course,  wash  clean  both  the  anterior  and  the  posterior 
urethra.  Should  the  second  part  be  clouded  from  pus  or  mucus,  this 
(in  the  absence  of  cystitis  or  pyelitis)  is  a  positive  sign  of  involvement 
of  the  posterior  urethra,  since  the  pus  produced  in  the  pars  posterior 
must  necessarily,  if  it  be  secreted  in  any  large  quantity,  first  fill  the 
prostatic  urethra,  and  then  flow  back  into  the  bladder  and  become 
mingled  with  the  urine.  If  there  be  but  a  small  amount  of  pus 
secreted,  it  will  remain  in  the  prostatic  portion  of  the  urethra  and  will 
be  carried  away  with  the  first  urine :  hence,  if  the  patient  micturates 
frequently  or  the  discharge  is  slight,  the  second  urine  will  probably 
remain  clear. 

In  this  case  the  source  of  the  pus  may  be  determined  by  passing 
a  small  soft  catheter  into  the  urethra  until  its  point  encounters  the 
resistance  caused  by  the  contraction  of  the  compressor  urethrse  mus- 
cle. All  the  pus  lying  in  the  anterior  urethra  is  now  washed  away 
by  forcibly  injecting  a  stream  of  water  through  the  catheter  until 
it  escapes  from  the  meatus  clear ;  six  or  eight  ounces  of  boric  acid 
solution  should  be  used  for  this  washing.  Immediately  after  this 
irrigation  the  patient  is  instructed  to  urinate  in  two  portions.-  If 
the  first  portion  of  water  passed  contains  pus,  while  the  last  part  is 
clear,  it  shows  that  there  is  inflammation  of  the  posterior  urethra, 
causing  a  discharge  not  sufficiently  profuse  to  fill  the  prostatic  urethra 
completely  and  flow  backward  into  the  bladder.  Even  this  test  is 
not  absolutely  accurate.  The  flushing  out  of  the  anterior  urethra 
with  a  one  per  cent,  solution  of  methyl  blue,  followed  by  urination 
and  microscopic  examination  of  shreds,  would  show  if  the  latter 
remained  unstained  that  they  probably  come  from  the  posterior 
urethra. 

It  is  only  in  acute  freely  discharging  cases,  then,  that  the  second 
urine  is  always  cloudy.  In  slight  cases  this  cloudiness  will  be  ob- 
served only  after  retention,  or  may  not  be  found  at  all. 

Since  there  is  prolonged  retention  of  urine  at  night,  it  is  best  to 
examine  the  urine  passed  in  two  portions  on  rising  in  the  morning. 
The  second  portion  of  this  will  nearly  always  show  the  presence  of 
pus,  even  though  the  posterior  urethritis  be  of  light  grade. 

3.  Ardor  urinoe,  or  pain  during  urination,  becomes  well  marked 
within  the  first  few  days.     The  pain  is  commonly  referred  to  the 


122  GEXITO-UPvIXARY   DISEASES   AND   SYPHILIS. 

meatus  or  to  the  navicular  fossa.  It  is  often  felt,  however,  along  the 
entire  anterior  urethra,  and  may  even  be  reflected  to  the  anal  region. 
This  pain  is  caused  mainly  by  the  action  of  acid  urine  on  the  inflamed 
mucous  membrane,  as  is  shown  by  the  soothing  effect  of  alkaline 
diuretics. 

Not  only  is  there  burning  on  urination,  but  from  slight  mechanical 
disturbance,  or  even  without  obvious  cause,  sharp,  cutting,  stabbing 
pains  are  felt  along  the  course  of  the  pendulous  urethra  at  various 
times.  These  may  be  so  constant  and  annoying  as  to  prevent  all 
but  absolutely  necessary  movements. 

4.  Painful  Erection. — Even  in  the  period  of  incubation  there  is 
usually  increased  sexual  excitement,  manifested  by  frequent  and 
long-continued  erections  and  even  by  increased  pleasure  in  copula- 
tion. As  the  inflammation  becomes  more  intense  and  wide-spread 
the  erections  become  more  persistent,  and  are  accompanied  by  pain 
which  is  often  so  severe  that  it  constitutes  one  of  the  most  harassing 
symptoms  of  the  disorder.  This  pain  is  due  to  the  fact  that  the 
congested  infiltrated  mucous  membrane  and  submucous  connective 
tissue  is  not  able  to  stretch  as  it  normally  does  when  the  cavernous 
bodies  become  engorged  with  blood.  The  tension  upon  the  now  non- 
elastic  urethra  is  still  further  increased  by  a  clonic  contraction  of  the 
ischio-cavernous  and  bulbo-cavernous  muscles,  which  swing  the  penis 
upward  against  the  abdominal  walls. 

Painful  erection  is  present  to  a  greater  or  less  extent  in  all  cases. 
It  occurs  most  frequently  during  the  sleeping  hours,  though  it  may 
give  trouble  at  any  time,  day  or  night.  The  pain  is  felt  mainly  along 
the  under  surface  or  on  the  sides  of  the  penis,  and  by  its  persistence 
either  awakens  the  patient  or  keeps  him  awake. 

Wlien  inflammation  is  unusually  severe,  chordee  develops, — that 
is,  during  erection  the  penis  is  curved  or  bent,  usually  downward, 
though  lateral  or  upward  curving  is  sometimes  observed.  In  these 
cases  the  pain  is  generally  severer  than  when  there  is  no  such  de- 
formity. The  marked  bending  of  the  organ  is  due  to  the  fact  that  the 
inflammation  extends  to  the  submucous  connective  tissue,  and  thence 
to  the  trabeculte  of  the  erectile  tissue  of  the  spongy  body.  The  exu- 
dation of  lymph  consequent  upon  this  fxlls  up  the  intertrabecular 
spaces,  which  by  engorgement  furnish  the  ordinary  mechanical  ele- 
ment of  normal  erection.  When  the  organ  becomes  erect  the  cor- 
pora cavernosa  are  fully  engorged  with  venous  blood.  The  infil- 
trated portion  of  the  corpus  spongiosum,  however,  remains  rigid 
and  undilatable,  the  blood  being  unable  to  find  its  way  into  the  par- 
tially obliterated  spaces.     If  the  inflammation  extends  to  the  corpora 


AFFECTIOXS  CHARACTERIZED  BY  URETHRAL  DISCHAKGE.     123 

cavernosa,  erections  will  be  equally  painful ;  but  in  this  case  the 
curve  will  be  upward.  If  only  one  cavernous  body  is  involved,  the 
curve,  of  course,  will  be  towards  the  affected  side. 

The  almost  unbearable  pain  of  chordee  may  lead  the  patient  to 
adopt  extreme  measures  for  its  relief.  At  times  the  arch  is  broken 
by  a  sudden  blow  of  the  fist,  the  penis  being  placed  on  some  hard, 
flat  surface.  The  result  of  this  treatment  is  a  rupture  of  the  urethra, 
either  partial  or  complete,  with  subsequent  formation  of  a  dense 
stricture  as  the  least  serious  consequence. 

At  times  patients  have  endeavored  to  obtain  relief  by  intercourse. 
The  results  are  nearly  as  disastrous  as  those  consequent  on  forcible 
breaking,  at  least  one  death  being  attributable  to  this  method  of 
treatment. 

The  inflammation  always  involves  the  posterior  urethra  extending 
back  thus  far  in  three  to  five  days.  Often  the  involvement  is  so  slight 
as  to  occasion  no  symptoms  other  than  the  presence  of  pus  in  the 
second  part  of  the  morning  urine  when  it  is  passed  in  two  portions. 
Prodromal  symptoms  of  acute  posterior  urethritis  may  not  be  ob- 
served before  the  end  of  the  second  week.  In  the  third  week  they  are 
usually  most  pronounced.  They  may  not  develop  till  a  much  later 
period, — in  the  course  of  relapses,  for  instance.  When  the  gonococci 
have  been  carried  backward  by  bougies  or  by  injections,  well-marked 
posterior  urethritis  may  develop  in  the  first  days  of  the  attack. 

Prostatitis,  vesiculitis,  epididymitis,  and  urethro-cystitis  are  the 
ordinary  complications  of  posterior  urethritis.  A  true  gonorrhoeal 
cystitis  is  extremely  rare,  and  is  always  due  to  mixed  infection,  since 
the  gonococci  are  not  prone  to  attack  surfaces  covered  with  squamous 
epithelium. 

Subacute  and  chronic  gonorrhoea  are  liable  to  be  complicated  by 
rheumatism,  ophthalmia,  endocarditis,  myelitis,  and  other  manifesta- 
tions of  septic  absorption. 

When  the  posterior  urethritis  develops  suddenly  as  a  result  of  ex- 
posure or  excesses,  it  runs  an  acute  course,  and  is  ushered  in  by  very 
characteristic  symptoms,  which  reach  their  height  in  one  or  two  days. 

The  attack  begins  with  painful,  urgent,  and  frequent  micturition 
and  the  appearance  of  pus  in  the  last  portion  of  urine,  associated 
with  an  attack  of  what  the  patient  calls  grippe  or  malaria.  In  severe 
cases  these  symptoms  are  followed  by  perineal  pain,  persistent  erec- 
tions, nocturnal  pollutions,  haematuria,  albuminuria,  and  sometimes 
retention  of  urine.  The  general  symptoms  are  much  like  those  of  a 
severe  attack  of  grippe. 

5.  Urgent  and  Frequent  Urination. -^Normally,  when  the  bladder  be- 


124  GENITO-URIXAEY   DISEASES   AXD   SYPHILIS. 

comes  moderately  distended,  the  internal  vesical  sphincter  dilates  and 
the  urine  comes  in  contact  with  the  prostatic  urethra.  This  occasions 
a  desire  to  urinate  so  slight  that  the  act  may  be  postponed  with  com- 
fort for  hours.  When,  however,  the  prostatic  urethra  is  inflamed  and 
hypersensitive,  the  first  contact  of  urine  on  the  yielding  of  the  internal 
sphincter  excites  an  uncontrollable  desire  to  evacuate  the  bladder 
contents. 

In  the  hyperacute  form  the  patient  is  compelled  to  micturate  every 
few  minutes,  but  passes,  after  great  straining,  attended  by  almost  un- 
bearable pain,  only  a  few  drops  of  urine,  without  any  relief  being 
afforded  to  the  intense  desire  to  urinate.  From  swelhng  of  the  mu- 
cous membrane  and  reflex  tonic  contraction  of  the  vesical  sphincters 
there  may  be  obstinate  retention  of  urine. 

When  inflammation  is  less  acute  the  constant  straining  is  replaced 
by  frequent  urination  and  a  precipitancy  in  the  act ;  that  is,  when  the 
desire  to  urinate  is  felt,  it  immediately  becomes  so  urgent  that  the 
water  is  retained  only  with  great  difficulty.  This  latter  symptom 
is  highly  characteristic,  and  is  readily  explained  on  physiological 
grounds. 

6.  Terminal  Hematuria. — In  addition  to  the  tenesmus  there  is  fre- 
quently hsematuria, — a  few  drops  of  pure  blood  running  from  the 
urethra  at  the  end  of  urination.  This  is  squeezed  from  the  swollen, 
congested,  often  eroded  mucous  membrane  of  the  prostatic  urethra. 
Hemorrhage  may  be  very  free.  In  this  case  the  blood  will  flow  back 
into  the  bladder,  and  the  patient  will  pass  it  mixed  with  his  urine  and 
after  the  latter  has  ceased  flowing. 

7.  Albuminuria. — During  the  period  when  vesical  tenesmus  is  most- 
marked  there  is  always  a  quantity  of  albumin  in  the  urine  greater 
than  can  be  accounted  for  by  the  pus  present.  This  is  probably  due 
to  damming  back  of  the  urine  in  the  ureters,  dependent  upon  closure 
of  the  orifices  of  these  canals  by  contraction  of  the  detrusor  muscles 
of  the  bladder,  this  having  been  shown  to  take  place  when  tenesmus 
is  severe. 

8.  Perineal  Pain. — This  when  due  to  tenesmus — i.e.,  muscular 
spasm — may  be  almost  unbearable  in  its  intensity.  Aside  from  the 
suffermg  by  muscular  spasm  there  are  usually  tickling,  burning,  or 
shooting  pains  in  the  deep  urethra  and  about  the  rectum.  These  are 
aggravated  by  micturition  or  defecation. 

9.  Erections  are  frequent,  but  are  painless  unless  there  is  at  the  same 
time  acute  anterior  urethritis. 

10.  Nocturnal  emissions  occur  repeatedly,  and  are  almost  sympto- 
matic of  inflammation  of  the  posterior  urethra.     They  are  due  to 


AFFECTIONS  CHAEACTEPvIZED  BY  UKETHKAL  DISCHAKGE.    125 

hypersesthesia  of  the  caput  gallinaginis,  and  are  often  painful,  the  dis- 
tress being  referred  to  the  deep  urethra. 

11.  Constitutional  Involvement. — Even  in  mild  cases  there  are,  as  a 
rule,  transitory  fever  and  slight  malaise.  Incident  to  acute  posterior 
involvement,  even  when  the  local  symptoms  are  not  especially  well 
marked,  there  are  often  pronounced  fever,  headache,  pains  through  the 
body,  particularly  in  the  back,  loss  of  appetite,  and  the  general  misery 
so  identified  with  "  grippe"  that  the  patient  himself  usually  makes  this 
diagnosis  of  his  condition. 

Unless  checked  by  appropriate  remedies,  the  symptoms  steadily 
increase  in  severity  for  about  two  weeks  ;  this  constitutes  the  increas- 
ing stage.  During  this  time  gonococci  have  invaded  the  entire  urethra 
and  have  penetrated  to  the  deepest  epithelial  layers. 

For  about  one  or  two  weeks  the  symptoms  remain  stationary 
(stationary  stage) ;  they  then  gradually  subside  (subsiding  stage), 
ardor  urinae  and  painful  erections  entirely  disappearing,  and  the  dis- 
charge becomes  thinner,  clearer,  and  more  scanty,  till,  in  about  two 
weeks  more,  it  is  entirely  suppressed. 

Acute  gonorrhcEa  may  be  greatly  prolonged  by  relapses  or  by  de- 
pressed conditions  of  the  system  rendering  the  tissues  less  able  to 
resist  or  eliminate  the  disease.  Relapses  may  be  occasioned  by  ex- 
posure to  cold,  by  over-exertion,  by  excesses,  or  by  the  congestion 
incident  to  seminal  emissions,  which  are,  in  turn,  excited  by  the  acute 
inflammatory  process. 

"  Russian  clap  "  is  the  vulgar  name  applied  to  gonorrhoea  of  a 
hyperacute  type.  In  these  cases  there  are  swelling  of  the  glans  and 
foreskin,  lymphangitis,  free  bloody  discharge,  great  sexual  excitement, 
frequent  seminal  emissions,  and  obstinate  chordee.  Bleeding  is  due  to 
rupture  of  the  intensely  congested  vessels  of  the  urethral  mucous  mem- 
brane, and  both  the  pus  and  the  semen  are  distinctly  blood-stained. 

Gonorrhoea  may  terminate  in  resolution  or  in  chronic  urethritis, 
or  may  be  followed  by  stricture. 

Comjylications. — In  the  increasing  stage,  balanitis,  balanoposthitis, 
phimosis,  and  paraphimosis  are  the  common  complications ;  in  the 
stationary  stage,  folliculitis  and  periurethritis,  lymphangitis,  lymph- 
adenitis, cavernitis,  and  Cowperitis. 

Prognosis  of  Acute  Gonorrhoeal  Urethritis. — This  specific  inflam- 
mation runs  its  course  in  from  five  to  eight  weeks.  If  carefully 
treated,  the  discharge  disappears,  the  urine  remaining  absolutely  clear 
of  shreds,  and  the  disease  is  cured.  At  times,  even  though  treatment 
has  been  judicious  and  has  been  rigidly  carried  out,  the  acute  inflam- 
mation runs  into  the  chronic  form,  manifested  by  a  gleety  discharge. 


126  GENITO-UEINARY   DISEASES  AND   SYPHILIS. 

lasting  longer  than  eight  weeks  ;  or,  in  the  case  of  the  posterior  urethra, 
by  constantly  recurring  subacute  attacks  and  sexual  neuroses  of  all 
types.  This  is  especially  liable  to  occur  in  the  strumous  and  cachectic, 
in  those  of  gouty  or  rheumatic  tendency,  and  in  patients  who  are  care- 
less in  respect  to  treatment  and  impatient  under  restraint.  The  prog- 
nosis as  to  the  time  when  cure  can  be  expected  must  always  be 
guarded. 

Treatment  of  Acute  Gonorrhoea  in  the  Male. — Prophy- 
lactic Measures. — The  use  of  a  cover  sufficiently  strong  to  remain 
unbroken  during  coitus,  followed  by  careful  ablution  and  urination 
immediately  on  completion  of  the  act,  is  the  only  reliable  means  of 
preventing  contagion.  In  the  majority  of  instances  the  cover  is  dis- 
pensed with,  the  washing  and  urination  being  relied  upon  to  dispose 
effectually  of  any  contagious  matter.  In  this  case  the  flushing  out 
of  the  urethra  may  be  made  more  thorough  by  passing  the  urine  in 
as  full  a  stream  as  possible  and  suddenly  stopping  its  flow  by  oc- 
cluding the  meatus.  This  widely  distends  the  anterior  urethra  and 
causes  the  water  to  penetrate  to  all  portions  of  the  fossa  navicularis 
and  even  to  the  lacuna  magna.  This  result  is  not  obtained  by  ordi- 
nary urination.  When  passed  in  the  way  directed,  the  mechanical 
cleansing  effect  is  superior  to  that  of  an  injection,  and  the  urine  is  at 
the  same  time  far  less  irritating  to  the  mucous  membrane. 

Among  those  who  are  constantly  in  the  habit  of  exposing  them- 
selves to  contagion,  the  employment  of  antiseptic  injections  imme- 
diately after  coitus  is  popular.  If  such  injections  are  employed,  they 
should  be  so  weak  that  no  irritation  of  the  mucous  membrane  will 
be  involved.  Since  it  has  been  shown  that  the  contagious  pus  does 
not  penetrate  deeper  than  the  fossa  navicularis,  the  injection  should 
not  extend  beyond  the  first  inch  of  the  urethra,  and  since  to  be 
efficient  the  injection  must  destroy  all  gonococci,  it  must  be  so  applied 
that  it  will  reach  every  portion  of  the  fossa  navicularis.  Protargol,  a 
grain  to  the  ounce  of  distilled  water,  is  probably  the  best  solution 
that  can  be  employed  as  a  prophylactic  injection.  Bierhoff  commends 
a  twenty  per  cent,  protargol  glycerin  solution,  three  minims  of  which 
are  dropped  into  the  fossa  navicularis. 

The  use  of  such  injections  should  be  preceded  by  urination.  Even 
when  they  are  most  skilfully  administered  they  do  not  afford  certain 
immunity  against  the  development  of  gonorrhoea.  Irritating  injec- 
tions may  in  themselves  cause  a  persistent  discharge  most  rebellious 
to  treatment. 

The  Abortive  Treatment. — The  treatment  of  gonorrhoea  in  its  early 
stages  by  strong  irritating  injections,  particularly  those  of  silver  nitrate, 


AFFECTIONS  CHARACTEKIZED  BY  URETHRAL  DISCHARGE.    127 

wjth  the  idea  of  substituting  an  acute  inflammation  for  the  specific 
process  and  thus  aborting  the  latter,  is  nciw  seldom  employed.  In- 
creased severity  and  longer  duration  of  inflammation  have  been 
noted  in  cases  thus  treated,  and  tight  strictures  are  much  more  fre- 
quently observed  than  when  gonorrhoea  is  treated  by  less  heroic 
measures.  There  is  reason  to  believe,  however,  that  employed  in  the 
right  way  and  at  the  right  time  the  abortive  treatment  of  gonorrhoea 
is  justifiable,  since  it  is  followed  at  times  by  prompt  cure,  and  if  it 
fails  it  does  not  seriously  aggravate  the  original  disease.  Two  meth- 
ods of  treatment  may  be  adopted  with  the  idea  of  aborting  the 
disease : 

1.  Injections  of  strong  solutions  of  organic  silver  salts. 

2.  Copious  flushings  with  weak  antiseptic  solutions. 

1.  Injections  of  Strong  Solutions  of  Silver  Salts. — It  has  been 
shown  experimentally  that  silver  salts  act  as  powerful  germicides 
upon  the  gonococcus.  Both  the  gonococcus  and  the  silver  salts  pro- 
duce the  same  effect  upon  the  urethral  mucous  membrane, — that  is, 
they  cause  a  desquamation  of  the  epithelium  and  an  active  inflam- 
mation of  the  deeper  structures.  The  silver  salts,  however,  act 
very  rapidly, — within  a  few  hours ;  the  gonococcus  requires  several 
days  to  produce  its  full  irritant  effects.  If,  then,  before  the  gono- 
coccus has  time  to  penetrate  more  deeply  than  the  superficial  layers 
of  the  epithelium  an  injection  of  silver  is  employed,  it  seems  fairly 
reasonable  to  hope  that  it  may  not  merely  destroy  the  microbes,  but 
may  also  cause  them  to  be  thrown  out  from  the  urethra  by  occa- 
sioning almost  immediately  an  active  inflammatory  discharge,  which, 
since  it  is  solely  due  to  a  chemical  irritation,  may  be  expected  to  sub- 
side entirely  within  a  few  days.  If,  however,  the  gonococcus  has  had 
time  to  penetrate  deeply,  further  irritation  cannot  accomplish  its 
extrusion,  but  will  simply  diminish  tissue  resistance  and  add  to  the 
pabulum  of  the  invading  microbe,  thereby  increasing  its  multiplying 
powers. 

It  is,  therefore,  clear  that  the  abortive  treatment  should  not  be 
attempted  except  in  the  very  earliest  period  of  a  gonorrhoea, — that  is, 
when  the  tickling  of  the  meatus,  the  drop  of  clear  or  slightly  cloudy  dis- 
charge, made  up  of  mucus  and  epitheliirtn,  and  the  extra  cellular  posi- 
tion of  the  gonococci  denote  that  the  inflammatory  process  has  not  ex- 
tended deeply.  A  red  or  injected  meatus  with  swollen,  everted  lips,  a 
turgid  glans,  marked  ardor  urinae,  and  particularly  free  purulent  secre- 
tion, constitute  absolute  contraindications  to  this  treatment,  even  if  the 
case  is  seen  early  in  its  course.  The  injection  should  be  made  of  five 
grains  of  protargol  to  the  ounce  of  distilled  water.     This  is  not  strong 


128  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

enough  to  produce  an  inflammation  of  sufficient  depth  and  intensity  to 
be  followed  by  subsequent  cicatricial  contraction.  The  patient  first 
urinates,  and  has  ten  drops  of  a  four  per  cent,  solution  of  eucaine  in- 
jected into  the  urethra.  Into  the  meatus,  the  lips  of  which  are  held 
open,  several  drops  of  the  protargol  solution  are  allowed  to  fall.  Then 
the  nozzle  of  the  syringe  is  introduced  and  about  bne  drachm  of  the  so- 
lution is  injected,  and  is  held  in  for  three  minutes  by  withdrawing  the 
syringe  and  compressing  the  meatus.  This  injection  is  repeated  every 
two  hours  ;  each  time  the  ounce  bottle  becomes  half  empty  it  is  filled 
to  the  top  with  distilled  water.  At  the  end  of  the  first  day  the  dilution 
becomes  1  to  200,  at  the  end  of  the  second  day  1  to  800,  at  the  end 
of  the  third  day  1  to  3200.  The  discharge  diminishes  and  becomes 
mucoid,  the  gonococci  disappear,  and,  if  the  treatment  prove  success- 
ful, there  may  be  complete  recovery  in  seven  days.  Even  though 
the  gonococci  disappear,  a  slight  discharge  often  persists. 

Usually  when  patients  appear  for  treatment  the  gonococci  have 
penetrated  to  a  depth  beyond  the  reach  of  the  silver  solution.  Even 
when  the  case  seems  suited  to  this  treatment  prognosis  as  to  prompt 
cure  must  be  guarded.  There  need  be,  however,  no  fear  lest  such 
treatment  should  directly  cause  stricture.  As  a  rule,  even  when  the 
injections  fail  to  eliminate  the  gonococci  and  check  the  discharge, 
they  do  not  after  the  first  day  aggravate  the  inflammatory  phenomena, 
increase  the  liability  to  posterior  complications,  or  prolong  the  treat- 
ment. 

In  this  or  in  any  other  abortive  method  of  treatment  the  patient 
should  be  given  directions  in  regard  to  diet,  exercise,  and  medication, 
w^hich  are  found  in  detail  under  the  Systematic  Treatment  of  Acute 
Gonorrhoea. 

2.  Copious  Flushings  ivith  Mild  Antiseptic  Solutions. — This  treat- 
ment is  sometimes  followed  by  rapid  cure  when  practised  in  the  early 
stages  of  gonorrhoea.  The  technique  of  this  method  is  described  later. 
(See  page  138.)     It  may  be  combined  with  the  injection  treatment. 

Systematic  Treatment  of  Acute  Gonorrhoea. — The  first 
point  to  be  considered  in  the  methodic  treatment  of  acute  gonorrhoea 
is  to  remove  as  far  as  possible  all  additional  sources  of  irritation. 
Among  these  are : 

1.  The  influence  of  bodily  activity,  which  always  occasions  more 
or  less  friction  and  local  congestion. 

2.  The  congestive  effect  of  sexual  excitement. 

3.  The  irritating  effect  of  acid  urine. 

The  best  way  to  avoid  the  deleterious  effect  of  bodily  exercise  is 
to  order  fest  in  bed,  thus  reducing  in  activity  all  the  processes  of  the 


AFFECTIONS  CHAEACTEEIZED  BY  UEETHEAL  DISCHAEGE.     129 

body  and  exercising  a  powerful  influence  in  controlling  local  con- 
gestion. This  is  well  shown  by  the  ease  with  which  gonorrhoea  is 
cured  in  hospital  practice.  Although  this  treatment  rarely  can  be 
carried  out,  it  is  useful  to  insist  upon  the  nearest  practicable  ap- 
proach to  it.  The  patient  should  be  instructed  to  avoid  all  active 
exercise,  to  walk  as  little  as  possible,  to  sit  rather  than  stand,  and, 
whenever  possible,  to  lie  down  with  his  hips  elevated. 

Since  inflammation  of  the  urethra  is  frequently  attended  by  marked 
sexual  erythism,  the  patient  should  be  made  to  understand  very 
clearly  that  the  hyperaemia  engendered  by  even  moderate  sexual 
excitement  distinctly  aggravates  the  inflammation  and  postpones  his 
cure :  hence  he  must  avoid  company,  reading,  or  thoughts  which 
might  produce  local  congestion. 

Careful  attention  to  diet  is  of  cardinal  importance  in  rendering  the 
urine  bland.  If  the  patient  can  be  limited  to  skimmed  milk  during 
the  increasing  stage  of  the  disease,  the  chances  are  largely  in  favor  of 
his  escaping  without  ardor  urinse  or  chordee.  Unfortunately,  very  few 
patients  can  adopt  this  diet,  since  so  marked  a  departure  from  the 
ordinary  regimen  would  be  certain  to  excite  attention.  In  such  cases, 
or  when  from  choice  the  patient  refuses  to  be  restricted  to  skimmed 
milk,  he  should  be  instructed  to  take  very  little  meat,  to  avoid  greasy, 
fried,  or  highly  seasoned  articles,  and  to  abstain  from  the  use  of  pep- 
per, vinegar,  salt,  coffee  or  tea,  salad  dressing,  asparagus,  acid  fruits, 
tomatoes,  pastry  of  all  kinds,  and  all  articles  of  food  difficult  of 
digestion.  Alcoholic  drinks  of  all  kinds  must  be  interdicted,  par- 
ticularly champagne,  beer,  and  gin.  If  to  avert  suspicion  it  becomes 
necessary  for  the  patient  to  take  some  form  of  alcoholic  hquor,  claret 
should  be  chosen  as  the  least  hurtful. 

Effervescing  mineral  waters  or  ordinary  water  may  be  taken 
freely,  but  not  to  the  extent  of  interfering  with  digestion.  Harassing 
painful  erections  are  controlled  by  potassium  bromide  one  to  three 
drachms,  camphor  monobromate  ten  to  twenty  grains,  or  hypoder- 
mics of  morphine  one-quarter  to  one-half  grain,  at  bedtime  ;  intense 
ardor  urinse  by  four  per  cent,  eucaine  solution  to  the  meatus,  or 
urinating  with  the  penis  hanging  in  hot  water. 

The  moderate  use  of  tobacco  is  rather  beneficial  than  otherwise, 
though  it  should,  of  course,  never  be  ordered  by  the  physician. 
Where  the  habit  is  already  formed,  and  is  practised  in  moderation,  it 
should  not  be  stopped.  Excessive  use  of  tobacco  should  always  be 
avoided. 

During  the  night  the  patient  should  sleep  on  a  hard  bed,  and 
should  not  be  too  warmly  covered.     He  should  rise  once  during  the 


]30  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

night  to  pass  water,  thus  not  only  washing  out  the  urethra,  but  also 
removing  a  cause  of  erection  and  consequent  local  congestion.  Before 
retiring  he  should  be  instructed  to  take  a  hot  bath,  lasting  from  ten  to 
twenty  minutes ;  this  by  equahzing  the  circulation  powerfully  modi- 
fies local  congestion.  It  is  often  an  efficient  means  of  lessening  or 
preventing  painful  erections.  The  bowels  should  be  moved  regularly, 
a  simple  saline,  such  as  effervescing  Vichy,  taken  early  in  the  morning, 
answering  well. 

For  the  purpose  of  rendering  the  urine  entirely  bland,  in  addition 
to  the  milk  diet  and  the  free  use  of  water,  it  is  well  to  prescribe  an 
alkahne  hydragogue  diuretic,  combining  with  it  an  arterial  sedative 
and  an  anodyne,  directed  especially  to  subduing  the  activity  of  the 
genital  function.  There  are  many  ways  in  which  these  ends  may 
be  attained,  but  the  following  prescriptions  satisfactorily  fill  the  indi- 
cations : 

R  Tinct.  aconiti  rad.,  gtt.  xvi ; 
Pot.  brom.,  Bviii ; 
Pot.  acetat.,  5ss ; 
Infus.  pareirae  bravae,  q.  s.  f^viii. 

M.     S. — f^ss  in  water  every  two  hours. 

B   Tinct.  verat.  vir.,  gtt.  viii ; 

Pot.  brom., 

Sod.  bicarb.,  aa  9 viii  ; 

Liquor  pot.  cit.,  f^viii. 
M.     S. — f^ss  in  water  every  two  hours. 

Two  five-grain  tablets  of  potassium  citrate  may  be  given  three 
times  a  day  after  meals. 

Dressing. — The  selection  of  a  dressing  which  shall  collect  and 
absorb  the  discharge,  and  which  shall  yet  be  neither  heating  nor  cum- 
bersome, is  a  matter  of  cardinal  importance.  The  use  of  the  rubber 
bags  or  pouches  sold  for  this  purpose  is  to  be  condemned  ;  the  securing 
of  dressings  by  tapes  or  bandages  bound  about  the  penis  is  also  objec- 
tionable. 

If  the  foreskin  entirely  covers  the  penis,  the  best  dressing  consists 
in  the  application  of  a  small  pledget  of  antiseptic  absorbent  cotton. 
This  is  retained  in  place  by  drawing  the  prepuce  forward.  It  should 
not  be  allowed  to  become  glued  tightly  to  the  meatus,  so  that  the  free 
escape  of  pus  will  be  interfered  with.  If  the  foreskin  only  partially 
covers  the  glans,  a  slit  should  be  cut  in  the  centre  of  a  piece  of  lint 
or  of  old  linen,  about  two  and  a  half  or  three  inches  square.  This 
slit  is  made  just  large  enough  to  slip  over  the  head  of  the  penis  and 
back  of  the  corona.     The  borders  should  be  turned  forward,  and  the 


AFFECTIONS  CHARACTEEIZED  BY  URETHRAL  DISCHARGE.     131 

foreskin  should  be  brought  in  the  same  direction,  thus  holding  the 
lint  or  the  linen  in  place.  If  the  foreskin  is  absent,  the  foot  of  an 
old  stocking,  or  a  bag  of  similar  size  made  out  of  any  thin  material, 
may  be  pinned  to  the  shirt  in  front ;  at  the  bottom  of  this  is  placed  a 
wad  of  absorbent  cotton,  and  the  penis  is  allowed  to  hang  in  the  bag. 
The  gonorrhoeal  bag  made  of  thin  permeable  fabric,  provided  with  a 
buttoned  flap  which  can  be  turned  down  readily,  and  fastened  as  is 
a  suspensory  bandage  around  the  loins  is  an  equally  efficient  and  more 
convenient  dressing.  Any  dressing  which  on  removal  is  followed  by 
the  immediate  escape  of  one  or  more  drops  of  discharge,  thus  showing 
that  there  is  a  damming  back,  should  be  discontinued. 

The  patient  must  be  cautioned  in  regard  to  the  contagious  nature 
of  the  discharge.  He  should  wash  his  hands  carefully  after  each 
handling  of  the  organ  or  of  the  dressing,  and  should  be  especially 
warned  of  the  danger  of  gonorrhoeal  conjunctivitis.  He  should  be  in- 
structed, in  addition  to  other  precautions,  to  keep  his  fingers  away 
from  his  eyes.  Since  gonococcal  infection  can  be  carried  by  means  of 
towels  in  the  bath,  particularly  to  female  infants,  the  patient  must  be 
informed  of  this  fact. 

The  directions  above  detailed  should  be  given  the  first  time  the 
patient  is  seen.  The  importance  of  rest  having  been  pointed  out,  the 
diet  having  been  regulated,  hot  baths  and  a  diuretic  mixture  having 
been  ordered,  and  the  proper  method  of  dressing  the  organ  having 
been  explained,  together  with  the  danger  of  infecting  the  eye,  the 
additional  treatment  will  depend  upon  the  nature  of  the  inflamma- 
tion. If  the  case  is  subacute,  the  discharge  will  become  more  pro- 
fuse, but  no  marked  subjective  symptoms  will  develop.  If  the  case 
is  one  of  acute  gonorrhoea,  symptoms  will  be  severe  in  inverse  pro- 
portion to  the  fidelity  with  which  the  regulations  given  have  been 
observed. 

The  subacute  may  be  subjected  at  once  to  the  injection  and  medi- 
cation appropriate  to  the  subsiding  stage  of  the  disease. 

The  acute  inflammatory  gonorrhoea  may  be  treated  (1)  by  internal 
medication,  supplemented  later  by  injections ;  (2)  by  immediate  anti- 
septic injections,  either  with  or  without  internal  medication ;  (3)  by 
copious  antiseptic  flushings. 

1.  Internal  Medication^  supplemented  by  Injections  in  the  Subsiding 
Stage. — The  general  directions  in  regard  to  rest,  diet,  the  regulation 
of  the  bowels,  the  dilution  of  the  urine,  and  the  dressing  of  the  penis 
having  been  given,  the  question  of  exerting  a  direct  germicidal  action 
upon  the  gonococci  and  at  the  same  time  increasing  tissue  resistance 
arises.     In  cases  hyperacute -from  the  first,  or  rendered  markedly  in- 


132  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

flammatory  in  type  by  excesses  or  irritating  injections,  or  in  those 
which  react  unduly  to  ordinary  applications,  many  surgeons  prefer 
postponing  local  treatment  till  the  subsiding  stage  is  reached,  holding 
that  thus  the  disease  runs  a  milder  and  shorter  course  and  that  compli- 
cations, particularly  those  associated  with  severe  posterior  urethritis, 
are  much  less  common  than  when  injections  are  used  earlier. 

If  such  a  treatment  is  adopted,  the  remedies  appropriate  to  the 
almost  inevitable  ardor  urinse  and  chordee  (page  129)  are  supple- 
mented by  drugs,  which,  when  they  are  eliminated  by  the  kidneys, 
exert  an  antiseptic  influence  on  the  gonococci,  at  the  same  time  slightly 
stimulating  the  urethral  mucous  membrane.  Exceptionally  even  the 
mildest  of  these  remedies  aggravates  the  urethritis,  or  so  disorders  the 
stomach  that  its  continuance  is  not  practicable.  Usually  the  drugs  com- 
monly employed  markedly  modify  the  amount  of  purulent  discharge 
and  the  violence  of  the  inflammatory  symptoms. 

Of  the  remedies  which,  administered  by  the  mouth,  render  the 
urine  mildly  germicidal,  the  most  potent  is  salol.  This  when  given 
alone  will  materially  modify  the  course  of  an  acute  gonorrhoea,  but 
when  combined  with  other  antiblennorrhagics  is  greatly  increased 
in  effectiveness.  After  salol  the  drugs  which  most  effectually  limit 
the  local  inflammation  are  oil  of  sandal  wood,  copaiba,  and  cubebs. 
Cubebs  and  copaiba  are  generally  used  in  the  subsiding  stage  of  the 
disease,  since  they  are  supposed  to  be  too  stimulating  during  the 
acute  stages ;  frequently,  however,  they  form  a  valuable  auxiliary  to 
the  antiseptic  treatment  from  the  very  beginning.  A  capsule  put  up 
according  to  the  following  formula  (White's)  will  not  only  abbreviate 
the  course  of  gonorrhoea,  but  will  often  prevent  the  development  of 
complications : 

R   Salol,  gr.  v  ; 

Oleoresin.  cubeb.,  gr.  v  ; 
Para  balsam,  copaibae,  gr.  x ; 
Pepsin.,  gr.  i. 

Or,  as  a  change  from  this,  capsules  containing: 

R  Salol,  gr.  iii ; 

01.  santal.,  gr.  iii ; 
Oleoresin.  copaibae,  gr.  iii ; 
01.  cinnamomi,  gt.  i. 

These  capsules  should  be  given,  the  former  four  to  six  a  day,  the 
latter  six  to  ten.  They  will  be  best  borne  by  the  stomach  if  adminis- 
tered an  hour  after  eating. 

An  emulsion  is  sometimes  better  tolerated  by  the  stomach.     The 
Lafayette  mixture  may  then  be  employed ;  this  is  made  up  as  follows : 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     133 

R   Balsam,  copaibse, 
Spir.  lavand.  comp., 
Spir.  seth.  nitrosi,  aa  ^ss  ; 
Liq.  potassae,  f^ss ; 
01.  gaultheriae,  f^ii ; 
Mucil.  acaciae,  q.  s.  ad  f,f  iv. 
M.     S. — Two  drachms  three  times  a  day  after  meals. 

Urotropin  has  shown  marked  antiseptic  powers.  Five  grains  are 
given  six  times  a  day  when  the  urine  is  alkaUne. 

When  these  drugs  seem  to  increase  local  inflammation  they  must 
be  stopped,  the  urine  being  rendered  mildly  antiseptic  by  a  blander 
remedy.  Boric  acid  answers  well  in  fifteen-grain  doses  four  times 
a  day.  A  useful  combination,  especially  when  there  are  symptoms 
of  vesical  irritation,  is  as  follows : 

R   Acidi  borici, 

Sodii  bromidi,  aa  ^Tiii ; 
Tinct.  belladonnse,  f,^i ; 
Liq.  potassii  citratis,  f.^viii. 
M.     S. — Tablespoonful  in  water  four  times  daily. 

The  possible  disagreeable  symptoms  excited  by  salol  and  the  bal- 
samic remedies  may  be : 

1.  Stomach  indigestion,  characterized  by  heaviness  after  eating, 
pain  in  the  stomach,  and  gaseous  and  liquid  eructations,  bringing  into 
the  mouth  a  taste  of  the  medication. 

2.  Copaiba  urticaria,  appearing  especially  upon  the  hands,  feet, 
arms,  knees,  and  abdomen. 

3.  Severe  backache,  fever,  albuminous,  smoky,  or  bloody  urine, 
and  sometimes  complete  suppression  of  the  secretion. 

Marked  kidney  disease  is  a  contra-indication  to  the  use  of  either 
salol  or  the  balsams,  but  not  to  urotropin. 

At  the  end  of  the  second  or  third  week  of  the  treatment  just 
described  the  inflammatory  symptoms  will  begin  to  subside,  and  the 
discharge  will  become  somewhat  thinner  and  less  abundant.  Without 
any  change  of  treatment  a  cure  may  be  expected  in  the  majority  of 
cases  in  ten  or  twelve  weeks.  This  cure  is  hastened  and  rendered 
more  certain  by  antiseptic  and  astringent  injections. 

Injections. — In  making  these  the  patient  is  directed  to  procure  a 
hard  rubber  urethral  syringe,  large  enough  to  hold  at  least  four 
drachms,  and  with  a  nozzle  so  shaped  that,  while  it  cannot  injure 
the  urethral  mucous  membrane,  yet  when  pressed  in  firmly  it  will 
occlude  the  meatus  entirely  and  thus  allow  the  injections  to  be 
conducted   in   a   cleanly  manner.      Either  the   blunt   hard   rubber 


134  GEJSTITU-rPvIXARY   DISEASES    AXD   SYPHILIS. 

urethral  syringe  of  the  American  Piubber  Comb  Company,  or  the 
Goodyear  syringe  No.  1  C,  should  be  selected.  (Fig.  58.)  Or  if  the 
patient  has  trouble  in  employing  a  piston  syringe,  a  soft  rubber  bulb 

provided  with  a  conical  point  may  be 

^^^- ^^; ^  ^^g^     ordered.   This  is  easily  kept  clean  and 

cannot  get  out  of  order.     It  is,  how- 
ever, ordinarily  more  difficult  to  use 

Uretural  synnge.  "^ 

than  is  the  hard  rubber  syringe,  pro- 
vided the  piston  of  the  latter  works  properly.  All  syringes  with  slender 
or  sharp  points  which  can  penetrate  for  some  depth  into  the  uretlira 
and  still  farther  inflame  the  mucous  membrane  must  be  forbidden. 

Having  procured  a  i)roper  syringe,  the  patient  should  be  instructed 
in  its  use  till  he  is  able  in  the  presence  of  the  surgeon  to  perform  upon 
himself  a  skilful  and  thorough  injection. 

In  making  the  injection  the  patient  may  either  sit  or  stand.  He 
first  urinates,  then  the  syringe  having  been  filled  is  taken  between  the 
thumb  and  middle  finger  of  the  right  hand,  the  tip  of  the  index  finger 
resting  on  the  piston.  The  conical  extremity  of  the  syringe  is  in- 
serted within  the  meatus,  which  is  held  open  for  that  purpose  by  the 
thumb  and  mdex  finger  of  the  left  hand,  and  which  is  then  drawn 
tightly  around  the  syringe,  the  pressure  being  made  laterally,  thus 
narrowing  the  aperture  instead  of  broadening  it,  as  would  happen  were 
it  compressed  vertically.  The  syringe  is  depressed  so  that  the  nozzle 
points  about  towards  the  umbilicus,  and  the  piston  is  then  driven  in. 

The  hquid  should  flow  into  the  urethra  Avithout  any  leakage ; 
should  dribbhng  occur,  it  shows  that  the  finger  and  thumb  of  the  left 
hand  are  not  so  placed  that  the  margins  of  the  meatus  are  made  to 
embrace  the  syringe  closely.  On  the  completion  of  the  injection  the 
syringe  should  be  quickly  withdrawn,  and  the  meatus  should  be 
instantly  closed  by  pressure  of  the  thumb  and  finger.  The  injection 
is  thus  retained  within  the  urethra  for  three  minutes.  The  whole 
anterior  urethra  should  be  distended.  This  requires  two  or  three 
drachms  of  solution,  and  w^hen  the  injection  is  first  driven  in  excites 
a  feeling  of  tension  and  muscular  spasm  in  the  perineum  correspond- 
ing to  the  position  of  the  bulb.  This  sensation  indicates  that  a  suffi- 
cient quantity  has  been  injected. 

The  soft  rubber  bulb  is  used  in  the  same  manner  as  the  syringe, 
except  that  the  liciuid  is  forced  out  by  compressing  its  sides  instead  of 
by  driving  home  a  piston. 

Any  injection  which  gives  rise  to  more  pain  than  may  be  char- 
acterized as  temporary  stinging  or  smarting  is  likely  to  do  more  harm 
than  good,  and  should  be  either  withdrawn  or  diluted.     Departure 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     135 

from  this  rule,  save  in  very  exceptional  circumstances,  is  likely  to  be 
followed  by  disastrous  results.  The  aim  of  the  surgeon  is  to  accom- 
plish cure  with  the  weakest  efficient  injection. 

These  injections  are  made  after  each  act  of  micturition. 

Injections  are  contra-indicated  in  acute  gonorrhoea  : 

1.  When  they  cause  persistent  and  severe  pain  and  seem  to  aggra- 
vate the  severity  of  the  inflammatory  symptoms. 

2.  During  the  course  of  an  acute  posterior  urethritis. 

The  injections  which  are  least'  irritating  and  most  successful  in 
shortening  the  course  of  acute  gonorrhoea  are  the  following : 

R    Argent,  iodid.  (thoroughly  washed),   3iii; 
Mucilag.  acac.   5  vi. 
S. — Use  locally  after  each  urination. 

Be  Hydrarg.  chlor.  corros.,  gr.  ^; 

Sod.  chlor.,  3! ; 

Aquae  destil.,  f.lvi. 
M.     S. — Locally  after  urination. 

R   Protargol,  gr.  v  ; 
Aquse  destil.,  f,^i. 
M.     S. — Solution  1  to  100  ;  add  twelve  drops  to  a  tablespoonful  of  distilled  water 
and  inject.     Gradually  increase  until  thirty  or  forty  drops  are  added. 

R   Pot.  permanganatis,  gr.  i  ; 
Aquae  destil.,  f^vi. 
M.     S. — Dilute  with  an  equal  quantity  of  boiled  and  filtered  water  and  inject. 
Gradually  increase  the  strength  of  the  injection. 

R  Zinci  permanganatis,  gr.  i ; 
Aquse  destil.,  f§vi. 
M.     S. — Dilute  with  an  equal  quantity  of  boiled  and  filtered  water  and  inject. 
Gradually  increase  the  strength. 

Such  injections  as  those  just  given,  containing  only  one  active 
principle,  are  usually  less  efficacious  than  those  in  which  the  anti- 
septic and  astringent  properties  of  two  or  more  drugs  are  combined  : 
hence  the  following  prescriptions  are  much  more  popular  and  effi- 
cacious when  injected  by  means  of  the  ordinary  syringe : 

R  Hydrarg.  chlor.  corros.,  gr.  2 ; 
Acidi  carbolici,  gr.  xii ; 
Zinci  sulphocarbolatis,  gr.  xii  to  ^i ; 
Boroglycerid.  (25  per  cent.),  f^ii ; 
Aquse,  q.  s.  ad  f^vi. 
M.     S. — Inject  after  urination,  diluting  or  making  stronger  according  to  indica- 
tions. 


136  GENITO-UEINARY  DISEASES   AND   SYPHILIS. 

This  injection  has  proved  more  efficacious  .than  any  other  of  the 
large  number  popular  with  the  profession.  It  is  appropriate  to  all 
stages  of  gonorrhoea,  the  strength  being  regulated  to  suit  individual 
peculiarities,  and  combines  nearly  all  the  essentials  theoretically 
required  of  an  injection. 

When  an  astringent  action  seems  to  be  strongly  indicated,  as 
shown  by  continued  profuse  muco-purulent  discharge,  uninfluenced 
by  antiseptics,  the  following  will  be  found  useful : 

R  Ext.  hydrast.  fl.  (colorless),  f^vi  ; 

Bismuthi  subcarb. ,  ^vi  ; 

Boroglycerid.  (25  per  cent.),  ,^vi  ; 

Aquae  destil.,  q.  s.  ^vi. 
M.     S. — Inject  after  urination. 

To  this  may  be  added  zinc  sulphocarbolate  in  the  proportion  of 
five  grains  to  the  ounce  of  water,  the  bismuth  being  replaced  by  this 
drug  towards  the  end  of  the  attack  to  enable  the  surgeon  to  determine 
the  nature  and  quantity  of  the  discharge. 

Another  astringent  injection  efficacious  in  the  last  weeks  of 
gonorrhoea,  and  serviceable  at  all  stages,  is  the  well-known  injection 
Brou.     This  is  compounded  as  follows : 

K  Zinci  sulphatis,  gr.  xv  ; 
Plumbi  acetatis,  gr.  xx  ; 
Tinct.  opii, 

Tinct.  catechu,  aa  3ii ; 
Aquae  ad  f^vi. 
M.     S. — Use  as  an  injection  after  urination. 

Ultzmann's  injection  is  particularly  efficacious  when  in  the  sub- 
siding stage  discharge  ceases  to  diminish  under  other  applications. 
The  formula  for  this  is  : 

R   Zinci  sulphatis, 

Pulv.  alum.,  aa  gr.  iv  ad  gr.  xii ; 
Acidi  carbolici,  gr.  iv; 
Aquae,  f,lvi. 
M.     S. — Use  by  injection,  changing  the  strength  in  accordance  with  the  indications. 

Other  astringent  injections  which  may  be  employed  are  : 

R  Zinci  acetatis, 

Acidi  tannici,  aa  gr.  xx  ; 
Aquae  rosae,  ^iv. 

R  Zinci  sulphatis,  gr.  iv  ad  gr.  xii  ; 
Liq.  plumbi  subacetat.  dil.,  f^iv. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     137 

When  the  discharge  has  entirely  disappeared  the  urine  should  be 
examined  to  see  whether  it  contains  clap-shreds.  If  these  are  present, 
there  must  for  a  time  be  no  abatement  in  the  treatment.  If  pus  is 
entirely  absent,  shreds  being  made  up  of  epithelium  and  mucus,  and 
other  symptoms  have  ceased,  the  patient  should  stop  treatment  gradu- 
ally. Injections  should  be  cut  down  to  two  a  day,  to  one  a  day,  to 
one  every  other  day,  until,  in  ten  days,  they  are  entirely  stopped. 

The  administration  of  antiseptics  and  balsams  by  the  mouth  is 
gradually  diminished  in  the  same  way,  the  urine  being  examined 
every  second  or  third  day  for  the  purpose  of  demonstrating  whether 
cessation  of  treatment  is  attended  with  reappearance  of  purulent  dis- 
charge. After  the  cessation  of  all  treatment  a  full  week  should  elapse 
before  the  patient  relaxes  the  strict  regimen  under  which  he  has  been 
living.  If  at  the  end  of  this  time  his  first  and  last  urine  is  entirely 
free  from  discharge,  he  can  safely  resume  his  ordinary  habits  of  life, 
at  least  so  far  as  relighting  his  gonorrhoeal  inflammation  is  concerned. 

Summary  of  Treatment  by  Intei^nal  Medication^  supplemented  by  In- 
jections in  the  Subsiding  Stage. — 1.  The  patient  is  directed  to  keep  as 
quiet  as  possible,  to  avoid  all  sources  of  sexual  excitement,  to  render 
the  urine  bland  by  diet,  to  secure  regular  daily  motions  of  the  bowels, 
to  take  a  hot  bath  before  retiring,  and  to  sleep  on  a  hard  bed  with 
light  covering. 

2.  He  is  given  remedies  calculated  to  make  the  urine  bland,  to 
subdue  local  inflammation,  and  when  excreted  by  the  urine  to  exert 
an  antiseptic  influence  on  the  gonococci  (as  salol,  oil  of  sandal  wood, 
copaiba,  sodium  bicarbonate,  sodium  bromide,  potassium  citrate  or 
acetate,  hyoscyamus,  belladonna,  aconite,  cubebs,  and  boric  acid). 
These  drugs  are  pushed  till  they  either  produce  disagreeable  effects 
or  accomplish  to  a  satisfactory  extent  the  object  for  which  they  are 
given. 

3.  The  treatment  appropriate  for  relief  of  ardor  urinae  and  chordee 
is  ordered.  In  the  beginning  of  the  subsiding  stage  an  injection  is 
given  after  each  urination.  These  injections  are  at  first  exceedingly 
weak,  are  gradually  increased  in  strength  as  toleration  is  established, 
and  are  made  more  distinctly  astringent  in  the  subsiding  stages. 

During  an  acute  posterior  urethritis  injections  of  the  anterior 
urethra  are  omitted. 

4.  Treatment  should  be  continued  till  examination  of  the  urine 
shows  absence  of  purulent  shreds  for  at  least  seven  days.  It  should 
then  be  stopped  gradually. 

The  treatment  of  discharge  lasting  longer  than  eight  weeks  will  be 
considered  under  the  heading  Chronic  Gonorrhoea. 


138  GENITO-URIXARY   DISEASES   AND   SYPHILIS. 

Treatment  by  Immediate  Injection. — This  differs  from  the  treatment 
just  described  only  in  the  fact  that  injections  are  ordered  as  soon  as 
the  patient  comes  under  observation  and  tlie  diagnosis  is  confirmed 
by  microscopic  examination.  The  general  directions,  the  internal 
medication,  and  the  injections  are  the  same  as  those  already  detailed. 
The  contra-indication  to  this  treatment  is  found  in  excessively  acute 
cases  which  are  distinctly  aggravated  by  any  form  of  local  treatment. 

The  injection  which  has  given  most  satisfactory  results  is  that 
made  up  of  zinc  sulphocarbolate,  carbolic  acid,  corrosive  sublimate, 
and  boroglyceride  (see  page  135),  supplemented  in  its  action  by  the 
salol,  copaiba,  and  cubeb  capsules  (page  132).  Care  must  be  taken 
that  the  injection  be  not  too  strong  when  it  is  first  applied.  This 
is  determined  by  the  amount  of  pain  excited  and  the  inflammatory 
reaction  which  follows  the  use  of  the  lotion.  The  first  injection  of 
any  lotion  should  usually  be  weakened  by  the  addition  of  an  equal 
quantity  of  sterile  water.  Towards  the  end  of  the  subsiding  stage  the 
strength  may  be  materially  increased.  Exceptionally  it  may  be  sub- 
stituted by  a  more  purely  astringent  lotion. 

Copious  Irrigation  of  the  Urethra  with  Dilute  Antiseptic  Solutions. — 
This   method   of  treatment,  applicable   at  any   stage  of  gonorrhoeal 
urethritis,  will  often  be  attended  with  more  rapid 
Fig.  59.  subsidence  of  inflammatory  symptoms  than  either 

of  the  methods  already  described.  The  apparatus 
required  is  a  quart  irrigating  bag  or  bottle,  a  rub- 
ber tube  leading  from  this  eight  feet  in  length,  and 
a  nozzle  attached  to  the  rubber  tube  and  shaped 
in  the  form  of  a  flattened  cone,  so  that  it  fits  into 
the  meatus  and  prevents  the  irrigation  liquid  from 
flowing  out  beside  it,  thus  keeping  the  urethra 
distended.     (Fig.  59.) 

In  place  of  the  urethral  nozzle  a  small  soft 

1II1-M11I1L1..1.,'.  rubber  catheter  (No.  10  F.)  may  be  fitted  to  the 

tube  leading  from  the  reservoir.      This  should 

be  lubricated  and  carried  down  to  the  compressor  urethrae  muscle 

when  it  is  desired  to  irrigate  the  anterior  urethra  alone. 

The  solutions  employed  in  the  irrigating  apparatus  are  bichloride 
of  mercury  1  to  20,000,  with  one  drachm  of  sodium  chloride  added 
for  each  pint  of  water ;  ammonium  sulpho-ichthyolate  1  to  2000  to 
500,  in  normal  salt  solution ;  potassium  permanganate  1  to  6000  to 
1000 ;  protargol  1  to  10,000  to  2000 ;  argyrol  1  to  2000  to  500. 

The  potassium  permanganate  solution  is  the  one  which  is  most 
popular  and  least  irritating,  at  least  in  the  early  stages  of  acute  gonor- 


AFFECTIONS  CHAKACTERIZED  BY  URETHRAL  DISCHARGE.     139 

rhoea.  This  is  used  as  hot  as  can  be  borne  with  comfort.  The  reser- 
voir is  filled  and  elevated  to  a  height  of  two  to  three  feet  if  the  anterior 
urethra  alone  is  to  be  irrigated,  to  a  height  of  four  to  six  feet  if  both 
the  anterior  and  the  posterior  urethra  are  to  be  medicated. 

The  patient  urinates,  cleanses  the  glans,  foreskin,  and  urethral 
orifice  by  turning  the  stream  from  the  nozzle  upon  the  parts,  then 
inserts  the  nozzle,  with  the  stream  still  flowing,  into  the  meatus,  the 
penis  being  drawn  slightly  upward  and  forward  in  about  the  position 
it  would  occupy  if  erect.  The  patient  should  sit  on  the  edge  of  a 
chair  with  a  basin  so  arranged  that  the  solution  which  escapes  is  re- 
ceived in  it,  or,  better  still,  should  practise  these  injections  wtiile 
sitting  on  the  seat  of  a  commode  or  water-closet.  When  the  anterior 
urethra  is  alone  involved  in  the  inflammation  these  irrigations  should 
be  limited  to  this  part  of  the  canal.  The  bag  should  be  elevated  two 
feet  above  the  level  of  the  bladder.  The  stream  should  be  allowed 
to  flow  until  a  sense  of  distention  in  the  bulb  and  involuntary  mus- 
cular contraction  in  the  perineum  show  that  the  anterior  urethra  is 
full  and  the  compressor  urethrse  is  excited  to  reflex  contraction.  The 
stream  is  then  cut  off,  and  the  lotion  contained  in  the  urethra  allowed 
to  flow  out.  By  starting  the  stream  and  applying  the  nozzle  to  the 
meatus  the  anterior  urethra  is  again  distended,  and  is  emptied  as 
before.  This  process  is  repeated  until  the  bagfu'  of  solution  has  been 
used. 

If  the  urethral  inflammation  is  total,  as  shown  by  examination  of 
the  urine, — and  this  is  nearly  always  the  case, — the  bag  is  elevated 
four  to  five  feet,  and  the  urethral  nozzle  is  held  in  place  with  the 
water-pressure  maintained  until  the  compressor  urethrse  yields  and 
a  strong  desire  to  urinate  shows  that  the  bladder  is  full.  The  nozzle 
is  then  withdrawn,  and  the  patient  empties  the  bladder  of  the  solu- 
tion which  has  flowed  into  it.  This  is  repeated  once  or  twice  at  each 
seance.  For  the  first  three  or  four  days  these  irrigations  are  repeated 
twice  in  the  twenty-four  hours, — that  is,  morning  and  evening ;  after 
that  once  in  twenty-four  hours  is  sufficient,  the  strength  of  the  solu- 
tion being  gradually  increased  in  accordance  with  the  tolerance  of 
the  urethra  and  bladder.  The  first  injections  should  be  made  of  a 
strength  of  1  to  6000  permanganate,  unless  inflammatory  action  is 
severe,  which  will  be  shown  by  persistent  pain  and  by  swelling  of 
the  meatus.  The  solution  is  strengthened  in  the  course  of  from  seven 
to  fourteen  days  till  a  lotion  of  1  to  2000  is  employed  ;  stronger  than 
this  should  not  be  introduced  into  the  bladder.  Exceptionally  1  to 
500  may  be  employed  in  the  anterior  urethra. 

When  sublimate  is  employed  the  strength  is  gradually  increased 


140  GENITO-UEIJfAPvY   DISEASES   AND   SYPHILIS. 

from  1  to  20,000  to  1  to  5000.     Protargol  is  used  in  about  the  same 
strength  as  potassium  permanganate. 

Janet  gives  two  tables  of  treatment :  one  for  the  abortive  treatment 
of  anterior  urethritis,  in  which  he  begins  with  a  strength  of  1  to  4000 
and  on  the  eighth  day  finishes  with  a  strength  of  1  to  500;  the 
second,  in  which  he  begins  with  the  same  strength,  on  the  fifth  day 
uses  1  to  1000  to  the  anterior  urethra,  1  to  2000  to  the  posterior,  and 
on  the  eighth  day  uses  1  to  500  to  the  anterior,  1  to  1000  to  the  poste- 
rior. He  holds  that  1  to  1000  is  as  strong  a  solution  as  should  ever 
be  used  in  the  posterior  urethra,  since  1  to  500  employed  here  will 
produce  painful  tenesmus.  In  the  first  few  hours  following  irrigation 
there  is  a  whitish  secretion,  followed  by  clear  serum,  sometimes 
slightly  blood-stained ;  then  absence  of  secretion ;  finally,  reappear- 
ance of  purulent  discharge,  together  with  the  gonococci.  The  return 
of  purulent  secretion  is  an  indication  that  the  effect  of  the  irrigation 
has  passed  off :  hence  these  washings  should  succeed  one  another  so« 
rapidly  that  this  recurrent  purulent  discharge  will  be  entirely  pre- 
vented ;  that  is,  the  second  irrigation  should  be  given  during  the  dry 
period  occasioned  by  the  first  irrigation. 

As  to  the  question  of  predicting  a  cure,  this  is  difficult.  Usually 
ten  or  eleven  washings  will  be  sufficient  to  bring  about  abortion.  At 
this  time  there  is  no  discharge  and  there  are  few  or  no  shreds.  Some- 
times there  is  a  little  mucous  discharge,  especially  if  a  strong  solution 
has  been  employed.  Iii  this  case  irrigations  are  stopped,  and  the 
patient  is  advised  to  continue  his  observance  of  the  hygienic  direc- 
tions, and  told  to  report  immediately  on  the  first  sign  of  white  dis- 
charge. In  the  absence  of  this  he  appears  eight  days  after  the  last 
irrigation. 

If  recurrence  takes  place,  the  discharge  usually  appears  from  the 
second  to  the  fifth  day  after  the  last  washing. 

In  case  of  recurrence  the  irrigations  are  again  administered  ;  some- 
times two  or  three  are  sufficient,  sometimes  it  is  necessary  to  give  the 
complete  series.  When  the  patients  are  cured,  eight  days  after  irriga- 
tion there  will  be  found  an  uninflamed  meatus,  and  entire  absence  of 
discharge  and  of  shreds  in  the  urine.  For  the  next  two  months,, 
however,  such  a  patient  will  be  especially  susceptible  to  renewed 
infection. 

Janet  holds  that  permanganate  has  a  peculiar  action  on  the  urethra. 
It  occasions  a  slight  oedema  of  the  urethra;  while  this  lasts  not  a 
single  microbe  can  be  found  in  the  secretion.  The  success  of  the 
permanganate  treatment  seems  to  show  that  the  microbes  are  so 
influenced    by   the   alteration   of    their    culture    ground,   dependent 


AFFECTIONS  CHARACTEEIZED  BY  URETHRAL  DISCHARGE.     141 

upon  the  oedema,  that  they  cease  to  grow  :  hence,  if  this  condition  of 
the  urethra  is  sufficiently  maintained,  the  complete  destruction  of  the 
microbes  is  sure.  It  therefore  follows  that  for  successful  treatment  it 
is  necessary  to  keep  the  mucous  membrane  continuously  in  a  certain 
condition  of  reaction.  If  the  treatment  is  carried  too  far,  the  growth 
of  the  microbe  is  encouraged ;  if  it  is  not  carried  far  enough,  inhibi- 
tion ceases.  This  special  reaction  is  fugacious  in  proportion  to  the 
acuteness  of  the  gonorrhoea :  hence  the  necessity  for  frequent  repe- 
titions of  the  injections.  The  special  skill  in  treating  this  disease 
depends  upon  recognizing  the  required  condition  of  reaction,  and  in 
so  regulating  the  strength  and  the  frequency  of  treatment  that  this 
condition  is  maintained  for  several  days. 

It  is  a  matter  of  cardinal  importance  in  applying  these  irrigations, 
and  indeed  in  any  treatment  of  gonorrhoea,  to  disinfect  thoroughly 
any  urethral  crypts  which  may  be  found  about  the  meatus.  On 
separating  the  lips  of  the  meatus  these  are  readily  seen  opening  at  the 
superior  commissure.  They  are  practically  always  present  in  cases  of 
hypospadia.  They  should  be  either  thoroughly  irrigated  or  cauterized, 
their  deepest  portions  being  reached  by  means  of  a  fine  stick  of  silver 
nitrate,  or,  better,  with  a  hot  needle.  When  they  are  narrow  and 
especially  deep,  their  canals  should  be  divided  freely,  thus  allowing 
of  thorough  cauterization.  From  the  position  of  these  crypts  it  is 
evident  that  unless  they  are  searched  for  and  treated  directly  they 
are  liable  to  remain  as  sources  of  renewed  infection,  since  the  nozzle 
of  either  the  syringe  or  the  injecting  pipe  is  carried  beyond  them,  and 
they  receive  none  of  the  antiseptic  fluid. 

When  examination  of  the  urine  shows  absence  of  clap-shreds,  or, 
if  these  are  present,  shows  that  they  are  made  up  of  mucus  and 
epithelium,  the  irrigations  can  be  gradually  stopped,  being  adminis- 
tered every  other  day  for  six  days,  then  every  third  day  for  six  more 
days,  then  omitted  entirely. 

When  there  is  continuance  of  mucous  discharge,  in  the  absence 
of  gonococci  and  a  notable  quantity  of  pus,  irrigations  of  silver  nitrate 
or  its  newer  organic  salts  are  particularly  serviceable.  If,  after  com- 
plete cessation  of  treatment,  there  recurs  a  white  drop  made  up  of 
mucus  and  pus,  irrigation  should  be  resumed,  and  usually  stops  the 
discharge  in  a  few  days.  If,  after  three  weeks'  treatment,  discharge 
persists,  astringent  injections  should  be  applied  to  the  anterior  urethra 
by  means  of  a  piston  syringe,  the  posterior  urethra  being  treated 
either  by  lotions  or  by  instillations,  according  to  the  indications  of 
the  case. 

The  advantages  of  the  irrigation  treatment  with  dilute  antiseptic 


142  GENlTO-URINAKY   DISEASES  AND   SYPHILIS. 

lotions  are,  that  the  discharge  lessens  almost  immediately,  that  the 
ardor  urinse  and  chordee  are  rarely  intense,  and  that  the  disease  in 
general  runs  a  milder  course  and  is  less  frequently  and  seriously 
complicated  than  is  the  case  with  injection  treatment.  Exceptionally 
the  urine  will  be  found  free  from  clap-shreds  in  from  twelve  to  four- 
teen days,  there  remaining  for  one  or  two  weeks  a  slight  moisture, 
which  subsides  spontaneously.  This  is  particularly  liable  to  be  the 
case  when  the  attack  is  seen  early  in  its  course  and  is  not  highly 
inflammatory  in  its  type.  It  often  happens,  however,  that  the  dis- 
charge, though  quickly  reduced  to  a  morning  drop  of  milky  pus  or 
to  the  morning  gluing  together  of  the  lips  of  the  meatus,  undergoes 
no  subsequent  diminution ;  clap-shreds  are  found  in  the  urine  in  the 
third  and  fourth  weeks,  and  strong  astringents  are  necessary  to  com- 
plete the  cure.  This  is  especially  hable  to  occur  when  the  disease 
has  reached  its  acute  stage  before  being  subjected  to  irrigation,  and 
when  the  urethra  is  already  strictured  by  previous  attacks  of  inflam- 
mation. In  the  former  ease  judicious  strengthenings  of  the  solutions 
may  accomplish  cure ;  in  the  latter  the  use  of  bougies  will  be  neces- 
sary to  effect  cessation  of  the  discharge. 

The  disadvantages  of  copious  flushings  are,  that  each  treatment 
takes  about  ten  minutes  for  its  proper  performance,  that  a  somewhat 
cumbersome  apparatus  is  required,  and  one  which  it  is  difficult  for 
the  patient  himself  to  employ  unobserved,  and  that  in  some  cases 
the  irrigations  are  followed  by  persistent  and  very  severe  pain.  It 
is  also  urged  against  them  that  it  is  at  times  impossible  to  hmit  their 
action  to  the  anterior  urethra,  it  being  undoubtedly  true  that  even 
when  a  soft  catheter  is  used  the  steady,  gentle  pressure  of  the  column 
of  fluid  will  in  a  few  minutes  overcome  the  resistance  of  the  com- 
pressor urethrse  and  sphincter  vesicae  muscles  and  thus  allow  the 
lotion  to  flow  backward  into  the  prostatic  urethra  and  the  bladder. 
This  is,  however,  not  an  objection,  since  the  prostatic  urethra  is 
usually  involved  and  requires  treatment.  As  is  true  of  every  other 
method  of  treatment,  these  copious  flushings  are  not  suited  to  all 
cases.  They  give  better  results,  however,  than  any  of  the  single 
methods  already  described,  and,  although  troublesome  and  time-con- 
suming in  application,  tend  to  prevent  complications  and  to  shorten 
the  course  of  the  disease.  During  irrigation  treatment  the  general 
hygienic  directions  and  the  medication  by  the  mouth  already  advised 
should  be  employed. 

It  must  be  understood  that  irrigations  are  contra-indicated  when 
they  occasion  severe  and  prolonged  pain  and  when  they  are  followed 
by  marked  inflammatory  reaction. 


AFFECTIONS  CHAEACTEEIZED  BY  URETHRAL  DISCHARGE.     143 

^  Treatment  of  Acute  Posterior  Urethritis. — It  may  be  assumed  that 
in  about  ninety  per  cent,  of  all  cases  of  gonorrhoea  the  posterior 
urethra  is  involved  in  the  inflammation.  Often  this  is  not  deep- 
seated,  and  occasions  no  special  symptoms  beyond  tendency  to  pria- 
pism, which,  though  usually  attributed  to  irritation  of  the  penile 
urethra,  is  in  reality  a  reflex  from  the  posterior  urethra. 

When  tenesmus,  frequent  urination,  and  pains  in  the  deep  urethra 
indicate  that  this  portion  of  the  passage  is  involved  in  a  hyperacute 
form  of  inflammation,  all  exclusively  local  treatment  to  the  anterior 
urethra,  such  as  injections,  should  immediately  cease.  As  much  rest 
as  possible  should  be  enforced,  the  bowels  should  be  moved  daily  by 
Hunyadi  taken  immediately  on  rising  or  by  saline  laxatives  well  di- 
luted, the  urine  should  be  rendered  copious  and  bland,  and  copaiba, 
cubebs,  or  other  stimulants  to  the  urethral  mucous  membrane,  if  they 
have  been  previously  administered,  should  be  discontinued. 

Unless  the  stomach  is  disturbed  by  these  \irugs,  salol  or  urotropin 
should  be  administered  in  live-grain  doses  four  times  a  day.  This  at 
times  seems  to  increase  the  violence  of  a  posterior  urethritis.  In  such  a 
case  boric  acid  should  be  administered  instead,  ten  grains  four  times  a 
day.  The  use  of  these  antiseptics  is  most  valuable  in  preventing  the 
extension  of  the  inflammation  along  the  vasa  deferentia  or  into  the 
bladder. 

General  hot  baths  are  particularly  serviceable  in  acute  posterior 
urethritis,  giving  sometimes  immediate  relief  to  the  most  distressing 
symptoms.  If  the  tenesmus  becomes  so  marked  as  to  occasion  acute 
distress,  suppositories  of  opium  and  hyoscyamus  should  be  adminis- 
tered, one  grain  of  the  aqueous  extract  of  opium  to  one-fourth  of  a 
grain  of  hyoscyamus  extract.  These  should  be  repeated  hourly  until 
the  patient  is  completely  relieved ;  four  to  six  doses  usually  prove 
sufficient.  In  place  of  the  suppositories  hypodermics  of  morphine  and 
atropine  may  be  given ;  the  needle  of  the  syringe  should  be  entered 
in  the  perineum. 

Copious  flushings  of  mild  antiseptic  solution  are  particularly 
serviceable  in  these  cases.  The  solutions  should,  however,  be  so  mild 
as  not  to  add  to  the  already  existing  irritation.  Potassium  per- 
manganate is  the  solution  of  choice,  beginning  with  a  strength  of 
1  to  10,000.  To  hot  permanganate  solution  is  added  common  salt  in 
the  proportion  of  one  drachm  to  the  pint.  Argyrol,  ichthargan,  and  al- 
bargin,  1  to  2000  to  500,  are  also  serviceable.  The  reflex  spasm  of  the 
compressor  urethrae  muscle  excited  by  the  posterior  urethritis  is 
sometimes  so  great  that  it  will  not  yield  even  though  the  reservoir  be 
elevated  six  or  seven  feet  above  the  level  of  the  bladder ;  or  when  it 


;[44  GENITO-UKINAKY   DISEASES   AND    SYPHILIS. 

yields  the  inflow  of  solution  through  the  prostatic  urethra  may  be  in- 
tensely painful.  In  these  cases  the  anterior  urethra  should  be  first 
flushed  out,  then,  by  means  of  the  instillator  introduced  just  within 
the  grasp  of  the  compressor,  ten  drops  of  a  four  per  cent,  solution  of 
eucaine  should  be  injected  into  the  posterior  urethra.  Exceptionally 
even  the  weakest  of  these  lotions  seems  to  aggravate  the  violence  of 
the  inflammation.  When  this  is  the  case  they  should  of  course  be 
discontinued,  and  copious  rectal  injections  of  hot  saline  solution  should 
be  made  by  a  two-way  pipe,  the  stream  being  thrown  upward  and 
forward  directly  against  the  prostate. 

In  the  hyperacute  forms  of  posterior  urethritis,  when  the  pains 
and  tenesmus  are  not  controlled  by  free  doses  of  morphine,  the-  in- 
stillation of  five  to  ten  drops  of  a  three  to  four  per  cent,  solution  of 
silver  nitrate  will  sometimes  give  almost  immediate  relief. 

During  the  irrigation  treatment  the  general  hygienic  directions  and 
medication  by  the  mouth  already  advised  should  be  employed. 

Resume  of  the  Treatment  of  Acute  Urethritis. — 1.  Non-gonococcal 
urethritis  may  be  treated  by  salol  and  boric  acid,  administered  by  the 
mouth.  The  urine  should  be  kept  bland.  Recovery  usually  takes 
place  in  from  seven  to  ten  days  ;  it  may  be  hastened  by  unirritating, 
mild,  antiseptic  injections, 

2.  Acute  gonorrhoea!  urethritis  may  be  aborted  sometimes  if  the 
infected  mucous  membrane  receives  twice  daily  permanganate  irriga- 
tions and  thorough  apphcations  of  strong  solutions  of  silver  salts  before 
the  gonococci  have  penetrated  too  deeply. 

3.  The  general  treatment  of  urethritis  is  the  same  for  all  cases : 
rest,  light  diet,  regular  evacuation  of  the  bowels,  ingestion  of  bland 
liquids  in  quantities  as  great  as  is  compatible  with  good  digestion,  ab- 
stinence from  alcohol,  from  rich  or  highly  seasoned  foods,  and  from 
the  excessive  use  of  tobacco,  avoidance  of  sexual  excitement,  hot 
baths  at  nights,  drugs  by  the  mouth  calculated  to  diminish  the  acidity 
of  the  urine  and  to  make  it  antiseptic,  proper  provision  for  receiving 
the  discharge,  and  the  treatment  appropriate  to  ardor  urinse  and 
chordee. 

4.  The  local  treatment  is  successful  in  proportion  to  the  thorough- 
ness with  which  mild  antiseptics  are  applied  to  the  entire  diseased 
surface.  The  earlier  in  the  attack  their  use  is  begun  the  more  rapid 
and  complete  will  be  the  cure. 

Copious  irrigations  of  hot,  very  dilute  antiseptics  are  attended  with 
most  marked  immediate  improvement,  but  are  not  always  able  to  pre- 
vent the  case  from  running  into  gleet.  These  irrigations  should  be 
applied  to  the  eiitire  urethra. 


AFFECTIONS  CHARACTEKIZED  BY  URETHRAL  DISCHARGE.     145 

Repeated  flushings  with  piston  or  bulb  syringe  somewhat  larger 
than  the  one  usually  employed,  using  the  same  solutions  as  are  em- 
ployed in  copious  irrigations,  come  next  in  order  of  efficiency  during 
the  increasing  and  stationary  stage  of  gonorrhcea. 

Single  injections  repeated  through  the  day  with  the  ordinary  piston 
syringe  have  a  less  marked  eff'ect  on  the  symptoms  than  either  of  the 
preceding  methods  during  the  increasing  and  stationary  stages.  During 
the  subsiding  stage  they  offer  the  most  convenient  method  of  applying 
stronger  antiseptic  and  astringent  solutions  than  are  usually  employed 
by  the  other  methods. 

5.  In  the  choice  of  local  medication,  the  increasing  and  stationary- 
stages  require  a  mild  antiseptic ;  astringent  action  is  useless.  Since 
all  antiseptics  are  irritating,  the  solution  must  be  exceedingly  dilute ; 
it  should  be  of  about  the  same  density  as  the  blood-serum,  and 
should  be  applied  to  the  whole  of  the  diseased  surface, — i.e.,  the 
entire  urethra.  In  the  subsiding  stages  stimulation  by  stronger  anti- 
septics is  allowable,  and  astringents  for  the  relaxed  mucous  mem- 
brane are  particularly  indicated. 

During  the  acute  stage  of  posterior  urethritis  treatment  of  the  ante- 
rior urethra  alone  should  cease,  local  symptoms  being  subdued  by 
copious  flushings  with  very  dilute  antiseptic  solutions,  hot  baths,  and 
the  administration  of  anodynes  and  sedatives.  When  the  acute  symp- 
toms subside,  the  flushings  may  be  with  stronger  antiseptic  lotions,  and 
may  be  supplemented  by  instillations  with  strong  silver  solutions. 

6.  Idiosyncrasies  must  always  be  considered  in  the  choice  of 
injections  and  in  their  strength.  Changes  must  be  made  to  meet 
individual  cases,  and  in  some  rare  cases  all  injections  will  have  to  be 
suspended,  intra-urethral  treatment  not  being  tolerated. 

For  irrigations  and  flushings,  sublimate  1  to  20,000,  potassium 
permanganate  1  to  8000  to  2000,  and  protargol  1  to  2000  to  500, 
give  best  results.  For  injections  the  formula  containing  corrosive 
sublimate,  carbohc  acid,  and  boroglyceride  (see  page  135),  varied  in 
strength  to  suit  each  case,  is  particularly  serviceable. 

When  astringents  are  required,  the  hydrastis-bismuth  formula, 
silver  nitrate,  the  injection  Brou,  or  Ultzmann's  injection,  containing 
zinc,  alum,  and  carbolic  acid,  will  be  found  most  serviceable. 

7.  Treatment  must  not  be  intermitted  till  pus  disappears  from  the 
urine,  and  even  then  must  not  be  stopped  suddenly. 

Subacute  or  Catarrhal  Gonorrhoea. — This  occurs  most  fre- 
quently in  persons  who  have  suffered  from  a  previous  attack  of 
gonorrhoea,  and  exempHfies  the  tendency  manifested  by  the  mucous 
structures  to  become    readily  excited   to  inflammation   from    slight 


146 


GENITO-URINAKY   DISEASES   AND   SYPHILIS. 


.^^^ 


Jp^v  ^Kc^^ 


causes  after  having  been  once  affected.  This  is  particularly  notice- 
able in  the  urethra,  because  this  canal  affords  periodical  passage  for 
the  urine,  which,  from  changes  in  its  constitution,  may  become  a 
natural  irritant.     During  erection  it  is  exposed  to  intense  congestion. 

On  account  of  its  excessive 
^'^-  ^^-  blood-supply  and  of  the  ab- 

sence of  firm  extra-vascular 
support,  the  blood-vessels 
remain  in  an  atonic  condi- 
tion and  become  greatly 
congested  on  slight  provo- 
cation long  after  apparent 
complete  recovery  from  an 
attack  of  urethritis.  The 
close  apposition  of  the  mu- 
cous surfaces  during  the  in- 
terval of  micturition  also 
favors  the  continuance  of 
granular  or  congested  areas 
or  other  traces  of  inflam- 
mation :  hence  but  few  who 
have  had  one  attack  of  gon- 
orrhoea escape  subsequent 
manifestations,  infection  too  feeble  to  overcome  the  resistance  of  a 
healthy  urethra  finding  under  such  circumstances  favorable  soil. 

Symptoms. — In  this  form  of  gonorrhoea  the  incubation  period  is 
exceedingly  variable  (one  to  ten  days),  and  there  is  often  no  inflamma- 
tory symptom  beyond  a  profuse  muco-purulent  urethral  discharge. 
There  may  be  a  slight  feeling  of  warmth  during  urination  and  some 
increased  sexual  excitability,  but  ardor  urinae  and  painful  erections 
are  usually  absent.  A  pure  pus  discharge  is  very  rare,  the  latter 
being  mainly  mucous  or  serous.  Gonococci  and  pus-cells  are  not 
abundant,  but  are  found,  together  with  epithelial  cells,  principahy  of 
the  flat  and  transitional  variety.  (Fig.  60.)  The  inflammation  seems 
to  be  purely  superficial  in  its  nature,  and  the  disease  is  rarely  attended 
by  local  complications.  This  form  of  discharge  should  be  differentiated 
from  that  due  to  urethral  syphilis.     (See  page  109.) 

Under  treatment  the  discharge  rapidly  diminishes  in  quantity  until 
only  a  drop  of  mucus  is  found  in  the  mornings ;  but  this  symptom 
is  liable  to  persist  for  a  long  period,  and  is  exceedingly  difficult  to 
suppress. 


Subacute  gonorrhoea  ;  pus  ;  epithelium ;  raised  infection. 
(Guy  on.) 


AFFECTIONS  CHARACTEEIZED  BY  URETHRAL  DISCHARGE.     147 

CHRONIC   GONORRHCEA. 

A  purulent  post-gonorrhoeal  discharge  lasting  more  than  ten  weeks 
is  indicative  of  chronic  urethritis,  or  gleet.  The  essential,  and  often 
the  only,  sign  of  chronic  urethritis  is  pus.  This  may  be  discharged 
from  the  meatus,  particularly  in  the  morning,  or  may  be  found  only 
after  careful  examination  of  the  urine. 

Etiology. — Chronic  urethral  discharge — that  is,  the  discharge  which 
follows  an  acute  or  subacute  gonorrhoea  and  persists — may  be  classed 
under  one  or  more  of  the  headings  given  on  page  102.  Thus  it  may 
be  kept  up  by  the  results  of  trauma,  particularly  that  due  to  irritating 
injections,  causing  persistent  inflammation  of  the  urethral  follicles  and 
Cowper's  glands  associated  with  gonococci. 

Frequently  repeated  fresh  infections  are  common  and  often  unsus- 
pected causes  for  the  recrudescence  of  an  apparently  cured  gonococcus 
infection. 

Perhaps  the  usual  cause  of  these  acute  exacerbations  is  incident  to 
a  neglect  of  treatment  incident  to  the  belief  that  the  disease  is  so 
nearly  cured  that  the  irksome  regimen  of  the  systematic  treatment  is 
no  longer  needful.  Excess  in  food  or  alcohol,  exposure  to  cold  and 
violent  exercise  render  the  urine  irritating.  Long-continued  sexual 
excitement  or  constipation  greatly  increase  local  congestion.  Thus 
the  subsidizing  inflammation  may  be  rendered  suddenly  and  violently 
acute  from  an  apparently  slight  cause. 

The  cachexia  associated  with  nephritis,  hepatitis,  diabetes,  tuber- 
culosis, or  cancer  may  make  the  final  cure  of  a  discharge  beginning 
as  a  frank  gonorrhoea  quite  impossible. 

A  localized  narrowing  of  the  urethra,  if  it  be  due  to  a  congenitally 
small  meatus  or  valvular  folding  of  the  urethral  mucosa  or  acquired  in- 
flammatory periurethral  infiltration,  may  keep  up  a  discharge  indefinitely. 

Irritating  conditions  of  the  urine,  such  as  are  found  in  oxaluria, 
phosphaturia,  gout,  rheumatism,  and  chronic  indigestion,  must  be 
corrected  before  a  gonorrhoea  can  be  finally  cured. 

The  usual  causes  of  chronic  anterior  urethritis  are  folliculitis, 
stricture  and  chronic  posterior  urethritis. 

Pathology. — The  chronic  inflammation  is,  at  least  in  the  early  period 
of  its  course,  dependent  on  the  persistence  of  gonococci,  which  linger 
for  a  long  time  either  in  the  diseased  gland-ducts  or  follicles  or  in  the 
deeper  epithelial  layers  of  the  mucous  membrane.  These  micro-organ- 
isms become  weaker  and  less  numerous  in  proportion  to  the  length  of 
time  the  disease  has  lasted,  till  finafiy  they  disappear  entirely.  The  pus 
may  be  actively  contagious  as  long  as  the  gonococci  are  contained  in  it. 


148  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

It  is  a  safe  rule  to  forbid  coitus  till  repeated  examinations  made 
during  periods  of  acute  exacerbations  have  failed  to  demonstrate 
gonococci. 

These  micro-organisms  exceptionally  persist  for  two  or  three 
years. 

Finger  has  shown  that  in  the  healing  stage  of  urethritis  the  newly 
formed  epithelium  growing  from  the  deeper  layers  towards  the 
urethral  lumen  carries  with  it  the  gonococci  and  finally  eliminates 
them  all,  provided  there  is  no  intercurrent  acute  inflammation.  If, 
however,  intercurrent  inflammation  occurs,  the  deep  epithelial  layer 
is  broken  through  by  the  exudate,  and  by  ways  thus  made  the  gono- 
cocci again  force  an  entrance  into  the  papillary  layers  and  by  their 
irritating  action  occasion  renewed  suppuration.  From  prolonged  resi- 
dence upon  the  same  culture  material  these  microbes  gradually  lose  their 
virulence,  and  hence  occasion  progressively  lighter  recurrences,  though, 
if  conveyed  to  others,  they  may  implant  a  severe  form  of  the  disease. 
Ultimately,  even  without  antiseptic  treatment,  they  disappear  entirely. 
As  a  result  of  this  lessened  virulence  after  repeated  recurrences  and 
renewed  penetration  of  the  now  feeble  gonococci  into  the  papillary 
layers,  they  may  excite  so  liitle  irritation  here  that  scarcely  any  sup- 
puration results,  and  hence  the  micro-oi^anisms,  not  being  eliminated, 
linger  indefinitely. 

The  lesions  of  chronic  urethritis  appear  as  intense  congestions,  ex- 
coriations, granulations,  epithelial  thickenings,  amounting  at  times  to 
excrescences  and  papillomata,  follicular  and  lacunar  involvement,  and 
infiltration  of  the  submucous  periurethral  connective  tissue,  resulting 
ultimately  in  stricture. 

The  inflammation  may  be  sharply  localized  or  may  be  associated 
with  a  catarrhal  condition  of  the  mucous  membrane  involving  con- 
siderable surface.  It  may  be  confined  to  either  the  anterior  urethra 
or  the  posterior  urethra ;  commonly  both  these  regions  are  involved. 

In  the  early  stage  of  chronic  urethritis  there  is  an  abundant  round- 
celled  infiltration  of  the  urethral  epithelium  and  subepithelial  con- 
nective tissue ;  the  epithelium  overlying  the  inflammatory  infiltrate 
proliferates  and  exfoliates,  leaving  catarrhal  erosions.  The  lacunae 
and  follicles  take  part  in  this  general  catarrhal  process,  and  as  a  result 
of  epithehum  proliferation  may  become  blocked,  folliculitis,  or  even 
abscesses,  resulting.  As  organization  and  contraction  of  the  infiltrate 
begin  and  the  previously  dilated  blood-vessels  are  compressed,  atro- 
phy of  the  mucous  membrane  and  its  glands  follows,  the  epithelium 
undergoing  transformation  from  the  cylindrical  to  the  squamous  form, 
varying  iii  thickness  in  proportion  to  the  density  of  the  underlying 


AFFECTIONS  CHAKACTERIZED  BY  URETHRAL  DISCHARGE.     149 

scar-tissue.  In  the  early  period  of  its  development  this  epithelium 
proliferates,  and  contributes  to  the  formation  of  clap-shreds ;  later  it 
becomes  more  firmly  attached  and  horny  in  nature.  When  the  cylin- 
drical epithelium  is  transformed  to  the  squamous  variety  it  is  no  longer 
translucent,  but  becomes  thick  and  whitish.  According  to  Finger, 
erosions  are  very  rare  ;  ulcers  he  never  observed.  He  frequently  saw 
patches  of  infiltrated  epithelium,  thickened  and  pale  in  color,  which 
resembled  scar-tissue. 

Morgagni's  follicles,  scarcely  visible  in  the  normal  urethra,  are,  as 
a  result  of  inflammation,  converted  into  small  projecting  nodules, 
often  with  very  distinct  openings. 

Finger  concludes  his  study  of  the  pathology  of  chronic  urethritis 
as  follows.  Chronic  gonorrhoea  is  essentially  chronic  inflammation  of 
the  subepithelial  tissue,  which  passes  through  two  stages, — namely, 
that  of  infiltration  and  that  of  connective-tissue  formation  and  con- 
traction. Together  with  this  essential  lesion  there  are  proliferation, 
catarrhal  desquamation,  and  mucoid  degeneration  of  the  epithelium 
of  the  urethra  and  of  its  lacunae,  also  disease  of  Littre's  glands  and 
infiltrations  of  the  cavernous  tissue.  Consecutive  to  these  lesions  the 
cylindrical  epithelium  is  changed  to  the  squamous  form,  the  lacunae 
are  obliterated  or  blocked,  and  Littre's  glands  are  destroyed. 

The  seat  of  predilection  for  chronic  urethritis  is  the  posterior 
urethra;  the  next  favorite  seat  is  the  bulb,  the  whole  of  which  is 
usually  involved. 

Diagnosis. — The  catarrhal  discharge  dependent  upon  a  weak  and 
leaky  mucous  membrane  and  associated  with  no  more  serious  patho- 
logical lesion  than  moderate  congestion  must  be  carefully  distinguished 
from  other  post-gonorrhoeal  gleets,  since  in  the  former  the  discharge  is 
bland  and  non-contagious,  and  local  treatment,  except  by  the  mildest  as- 
tringents, is  distinctly  contra-indicated.  This  condition  may  be  termed 
urethral  catarrh.  After  an  acute  attack  of  gonorrhcEa  has  subsided 
and  the  last  drop  of  muco-pus  has  disappeared,  a  patient  suffering 
from  this  trouble  will  harass  himself  and  weary  his  physician  by 
complaining  of  a  feeling  of  wetness  about  the  meatus.  Sometimes  on 
stripping  the  urethra  a  drop  of  clear  albuminoid  fluid  may  be  pressed 
out.  Beyond  this  there  are  no  symptoms  other  than  those  created 
by  a  worried  imagination.  The  microscope  will  at  once  show  the 
nature  of  the  discharge.  It  will  be  made  up  of  mucus  and  epithelium. 
There  will  be  no  pus,  no  gonococci. 

Under  general  tonic  and  hygienic  treatment  this  discharge  will  usu- 
ally subside  spontaneously  in  a  few  weeks  unless  the  slight  congestion 
is  fanned  to  an  active  inflammation  by  irritating  local  treatment,     i-^:- 


X50  GEXITO-UEIXAET   DISEASES   AND   SYPHILIS. 

Acute  gonorrhoea  frequently  runs  into  the  chronic  form  of  disease 
because  of  a  general  belief  in  the  doctrine  that  the  presence  or  the 
absence  of  the  "  morning  drop"  of  muco-pus  is  the  determining  sign 
as  to  whether  an  acute  gonorrhoea  is  or  is  not  cured.  Dependence 
on  this  untrustworthy  sign  leads  to  abandonment  of  treatment  and 
restraint  long  before  gonococci  and  pus  have  entirely  disappeared. 
The  strict  regimen  to  which  the  patient  has  been  subjected  is  often 
followed  by  excessive  indulgence  in  previously  interdicted  pleasures. 
This  results  in  renewed  perceptible  discharge.  This  again  disappears 
on  treatment,  but  is  started  by  exposure  even  more  readily  than 
before.     Finally  the  discharge  becomes  chronic. 

Repeated  examination  of  the  urine  will  alone  determine  the  pres- 
ence or  absence  of  discharge,  and  not  until  such  examinations  have 
shown  pus  to  be  absent  for  one  or  two  weeks  should  treatment  be 
entirely  stopped. 

To  demonstrate  the  presence  of  the  gonococci  in  clironic  urethral 
discharge  examinations  must  be  made  of  the  semen,  the  fluid  expressed 
by  prostatic  massage,  and  the  shreds  in  the  urine.  If  a  demonstration 
of  their  presence  or  absence  is  particularly  important,  this  may  be 
determined  by  adding  to  the  chronic  irritation  an  acute  inflammation. 
This  is  best  accomplished  by  injection  of  silver  nitrate  1  to  2000. 
There  follow  an  active  hyperaemia  and  free  discharge,  in  which  the 
micro-organisms,  stimulated  to  rapid  growth  by  the  abundant  supply 
of  pabulum  incident  to  the  acute  mflammation  and  thrown  off  in  the 
course  of  epithelial  proliferation,  may  be  found. 

Clironic  Anterior  Urethritis. — The  only  symptom  exciting  at- 
tention in  chronic  anterior  urethritis  is  the  discharge.  If  this  is  slight 
and  the  focus  of  trouble  is  in  the  bulbous  urethra,  even  this  symp- 
tom may  be  wanting,  the  patient  simply  complaining  of  a  sense  of 
moisture  about  the  meatus,  or  of  the  gluing  together  of  its  lips,  in  the. 
morning.  Usually  a  single  whitish  drop  in  the  morning  is  all  that  is 
seen,  micturition  during  the  day  washing  away  the  muco-pus  as  fast 
as  it  is  secreted,  so  that  the  patient  is  not  required  to  wear  cotton  or 
other  protection  to  prevent  staining  of  the  clothing.  Coitus,  drinking, 
or  other  excesses  tend  to  exaggerate  the  discharge.  After  such  causes 
for  exacerbation  it  becomes  more  purulent  in  character  and  runs 
freely  for  a  few  days,  when  it  again  assumes  the  thin,  whitish  appear- 
ance characteristic  of  a  predominance  of  mucus. 

Clap-shreds  are  constantly  found  in  the  urine ;  these,  when  long, 
translucent,  and  branching,  are  mainly  made  up  of  mucus ;  when 
short,  thick,  and  tack-  or  comma-shaped,  they  denote  that  the 
urethral  crypts  and  follicles  are  involved. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     151 

Symptoms. — The  characteristic  symptom  of  chronic  anterior  ureth- 
ritis is  muco-purulent  discharge.  This  varies  greatly  in  quantity, 
from  a  free  continuous  running  to  a  morning  drop  without  further 
signs  during  the  day,  to  a  shght  gluing  of  the  lips  of  the  meatus,  or  to 
no  discharge  whatever  except  that  found  floating  in  the  urine  in  the 
form  of  clap-shreds. 

The  discharge  varies  in  quality  from  thick  yellow  or  yellow-green 
pus  to  thick  muco-pus  containing  the  micro-organisms  of  suppuratior?, 
or  to  nearly  pure  mucus  containing  a  very  few  pus-cells  and  not  show- 
ing the  presence  of  gonococci.  It  is  commonly  intermittent,  becoming 
frankly  purulent  and  flowing  freely  after  excesses  or  lapses  from  the 
irksome  routine  of  methodic  treatment,  or  without  assignable  cause, 
but  quickly  lessening  in  quantity  under  astringent  injections  till  in  a 
few  days  the  discharge  is  about  the  same  as  before  the  exacerbation. 
This  intermittence  is  misleading  to  the  patient,  since,  on  the  one 
hand,  it  may  convince  him  that  he  is  well  or  nearly  so  when  the  dis- 
ease is  still  active,  and,  on  the  other  hand,  it  often  leads  him  to  sus- 
pect that  he  has  acquired  a  fresh  attack  when  symptoms  are  due 
simply  to  the  stirring  up  of  an  inflammation  so  slight  as  not  to  have 
excited  attention. 

Discharge  is  usually  the  only  symptom  ;  occasionally  there  are  in- 
termittent ardor  urinse,  neuralgic  pains  along  the  course  of  the  urethra, 
and  dribbling  after  urination. 

Diagnosis. — This  is  founded  on  the  discharge,  and  on  the  char- 
acter of  the  urine  passed  in  two  portions,  the  first  containing  clap- 
shreds,  while  the  last  is  clear ;  the  first  is  also  clear  after  flushing  of 
the  anterior  urethra.  The  clap-shreds  should  always  be  examined 
for  gonococci.  This  is  done  by  spreading  them  on  a  cover-glass, 
removing  the  urine  in  which  they  float  by  means  of  blotting-paper,  and 
then  fixing  and  staining  them  in  the  ordinary  way.     (See  page  115.) 

Examination  may  be  conducted  by  means  of  palpation,  and  by  the 
use  of  the  bulbous  bougie  or  the  urethroscope. 

By  palpation  along  the  course  of  the  urethra  areas  of  tenderness 
and  points  of  thickening  may  be  felt.  Polyps,  or  the  circumscribed 
induration  of  a  chronic  folliculitis,  may  be  detected. 

Instruments  should  not  be  used  till  the  disease  is  distinctly  local- 
ized and  chronic ;  then  the  bulbous  bougies  should  be  passed.  The 
patient  is  first  instructed  to  urinate ;  after  he  has  done  this  a  soft 
catheter  should  be  passed  to  the  bulbo-membranous  juncture,  and 
by  means  of  a  stream  of  weak  bichloride  solution  (1  to  20,000)  driven 
through  it  the  anterior  urethra  should  be  washed  free  of  discharge. 

A  thoroughly  cleansed  bulbous  bougie  as  large  as  the  meatus 


152  GENITO-UKINAPvY   DISEASES   AND   SYPHILIS. 

will  admit  should  then  be  sterilized,  well  lubricated  with  carbolized 
glycerin,  and  gently  introduced  into  the  urethra.  Points  of  special 
tenderness  or  of  undue  resistance  should  be  noted.  If  the  exami- 
nation of  the  urine  shows  that  the  inflammation  is  confined  to  the 
anterior  urethra,  the  bougie  should  not  be  passed  beyond  the  bulbo- 
membranous  juncture.  The  resistance  of  the  compressor  urethrse 
muscle  and  the  distance  from  the  meatus  will  show  when  it  has 
reached  this  point.  It  should  then  be  withdrawn.  Pus  and  blood 
upon  its  shoulder  will  denote  either  erosions  or  an  extremely  con- 
gested condition  of  the  mucous  membrane.  The  seat  of  the  lesion  is 
often  determined  by  the  locahty  of  the  most  severe  pain  attendant 
upon  the  introduction  and  withdrawal  of  the  instrument,  and  in  the 
later  stages  by  an  increased  resistance  to  the  passage  of  the  instrument 
at  that  point.     (See  diagnosis  of  stricture,  page  220.) 

The  urethroscope  may  be  employed  for  the  purpose  of  more  ex- 
actly determining  the  locality  and  nature  of  the  lesions  and  as  a  means 
of  making  strong  applications  to  strictly  localized  inflammation,  though 
it  may  often  be  dispensed  with,  the  diagnosis  being  made  and  the 
treatment  carried  out  with  sufficient  accuracy  by  the  means  already 
described. 

Sometimes,  though  the  rest  of  the  urethra  is  healthy,  an  annoying 
discharge  is  kept  up  by  chronic  inflammation  of  the  periurethral 
crypts  opening  at  the  borders  of  the  meatus  near  the  posterior  com- 
missure. In  this  case  examination  of  the  everted  lips  of  the  meatus 
will  show  the  dilated  opening,  from  which  pus  can  be  squeezed. 

Prognosis. — In  general  terms  the  curability  of  gonorrhcea  is  in 
inverse  proportion  to  its  duration.  In  other  words,  the  longer  the 
disease  lasts  the  deeper-seated  it  becomes  and  the  more  obstinate  to 
treatment.  Stricture  is  the  usual  sequel  of  chronic  urethritis,  and 
when  once  developed,  even  to  the  slightest  degree,  tends  indefinitely  to 
prolong  urethral  catarrh.  The  length  of  time  during  which  the  dis- 
charge of  chronic  urethritis  is  contagious  cannot  positively  be  stated. 
When,  after  repeated  examinations  of  an  artificially  exacerbated  dis- 
charge, no  gonococci  are  found,  it  is  fair  to  infer  that  none  are  present ; 
yet  it  must  be  admitted  that  it  is  not  safe  to  give  an  absolute  opinion 
upon  this  point,  since  thus  the  physician  takes  upon  himself  the  re- 
sponsibility of  permitting  intercourse,  which  has  in  some  few  cases 
been  followed  by  infection  of  the  woman. 

Treatment  of  Chronic  Anterior  Urethritis. — The  most  important 
points  in  the  treatment  of  any  chronic  urethral  discharge  are  (1)  the 
restoration  of  the  urethra  to  its  normal  calibre ;  (2)  the  cure  of  the 
general  catarrh  ;  (3)  the  healing  of  localized  areas  of  inflammation. 


AFFECTIONS  CHAEACTERIZED  BY  URETHKAL  DISCHARGE.     J  53 

A  meatus  of  less  than  24  F.  should  be  cut.  (Seepage  243.)  Dila- 
tation is  accomplished  by  full-sized  sounds,  or,  better,  by  a  rubber- 
covered  dilating  instrument,  which  being  introduced  closed  to  the 
bulbo-membranous  juncture,  is  opened  to  the  proper  calibre  and 
withdrawn,  thus  milking  the  urethral  crypts  and  follicles  from  behind 
forward.  The  Otis  urethrameter  or  the  prostatic  dilator  (page  163) 
answers  well  for  this  purpose.  The  urethra  is  then  flushed  with  a 
mild  antiseptic  lotion, — protargol  1  to  2000  or  ichthyol  1  to  1000, — and 
the  patient  is  requested  to  appear  for  another  treatment  in  two  or  three 
days.  (See  page  236.)  In  the  mean  time  he  uses  daily  either  irriga- 
tions or  the  more  astringent  injections,  and  continues  his  general  treat- 
ment.   Salol  and  balsams  are  given  by  the  mouth,  the  latter  in  full  doses. 

This  treatment  by  sounding  and  irrigation  is  repeated  every  two  or 
three  days,  in  accordance  with  the  severity  of  the  reaction  it  excites, 
and  is  usually  followed  by  cure  in  from  two  to  six  weeks.  The 
pressure  of  a  full-sized  sound  empties  the  folhcles  of  their  contents, 
sets  up  a  reactive  inflammation  in  the  areas  of  infiltration,  which  is 
followed  by  absorption  of  the  inflammatory  infiltrate,  and  restores 
the  tonicity  of  the  over-distended  blood-vessels.  The  first  essential 
in  the  cure  of  the  discharge  is  the  restoration  of  the  urethra  to  its 
normal  calibre. 

When  urethroscopic  examination  shows  localized  areas  of  acute 
hypersemia,  or  erosions,  or  infiltration  and  inflammation  about  the 
urethral  follicles,  or  granular  patches,  or  papilloraata,  or  polypi,  these 
lesions,  though  benefited  by  the  introduction  of  the  sound,  are  most 
quickly  cured  by  direct  application  of  strongly  stimulating  lotions. 
Such  applications  can  be  made  only  by  means  of  a  urethroscope. 
The  lesion,  having  been  exposed,  is  touched  with  a  ten-grain  solution 
of  silver  nitrate,  or  copper  sulphate,  or  pure  iodine,  or  a  bichloride  of 
mercury  1  to  100  solution,  or  an  alcoholic  solution  of  carbolic  acid 
ten  per  cent.,  or  Lugol's  solution  and  carbohc  acid  equal  parts  of 
each.  Applicators  are  conveniently  made  of  split  straws,  barbed  at 
the  end  to  prevent  the  cotton  wrapped  about  them  from  dropping 
into  the  urethra. 

In  the  choice  of  these  remedies,  silver  nitrate  is  most  serviceable 
in  the  treatment  of  comparatively  superficial  catarrhal  conditions 
not  strictly  localized,  and  particularly  during  the  early  stages  of  the 
chronic  disease.  In  the  beginning  weak  solutions  should  be  tried,  not 
stronger  than  two  per  cent.  The  strength  should  be  gradually  in- 
creased as  the  patient  is  able  to  bear  it. 

Inflamed  follicles  are  treated  by  the  application  of  the  galvano- 
cautery  needle,  or  of  iodine  and  carbolic  acid  mixture.     Granular  sur- 


154  GENITO-URINAKY   DISEASES   AND  SYPHILIS. 

faces  do  better  under  this  latter  remedy  than  under  silver  nitrate.  The 
choice  of  the  various  remedies  is,  however,  subject  to  no  set  rule.  They 
should  be  changed  or  continued  in  accordance  with  the  results  they  give. 

Following  the  use  of  the  endoscope,  and  sometimes  follovdng  in- 
strumentation, there  are  profuse  discharge,  sometimes  bleeding,  and 
usually  ardor  urinae.  After  two  days,  especially  when  astringent 
injections,  such  as  the  alum,  zinc,  and  carbolic  acid  mixture,  are  taken 
by  the  patient,  the  discharge  disappears.  These  endoscopic  applica- 
tions are  repeated  not  oftener  than  once  in  three  or  four  days,  and 
exceptionally  cause  prompt  subsidence  of  discharge.  Usually  they 
have  to  be  continued  for  several  weeks  before  cure  is  effected. 

Polyps  or  papillary  outgrowths  may  be  removed  by  curette,  by 
caustics,  or,  best  of  all,  when  these  growths  are  sessile,  by  the  gal- 
vano-cautery  applied  through  the  endoscope. 

In  certain  cases  the  use  of  the  endoscope  either  does  not  better 
the  patient's  condition  or  distinctly  aggravates  the  urethral  discharge. 
Then,  even  though  its  use  is  apparently  indicated  by  the  nature  of 
the  lesions,  it  should  be  supplanted  by  other  methods  of  treatment ; 
preferably  irrigation  and  dilatation. 

Irrigations,  particularly  with  solutions  of  full  strength,  are  quite 
as  valuable  in  chronic  as  in  acute  urethritis.  The  reason  for  their 
failure,  and  also  for  the  failure  of  treatment  by  injections,  is  that 
chronic  urethritis  is  rarely  confined  to  the  anterior  urethra,  and 
hence  treatment  directed  to  this  portion  of  the  passage  alone  fails  to 
reach  the  seat  of  trouble. 

Chronic  Posterior  Urethritis. — Pathology. — The  pathology  of 
chronic  posterior  urethritis  is  similar  to  that  of  long-standing  inflam- 
mation of  the  anterior  urethra.  Finger  states  that  from  the  first  there 
is  a  round-cell  infiltration  of  the  subepithehal  connective  tissue,  which 
subsequently  undergoes  organization  and  contraction.  This  infil- 
tration is  commonly  superficial,  though  in  cases  of  long  standing  it 
extends  more  deeply,  involving  the  prostatic  glands,  the  sinus  pocu- 
laris,  and  the  ejaculatory  ducts,  producing,  in  the  stage  of  contraction, 
destruction  of  the  lacunae  and  superficial  glands,  and  at  times  oblit- 
eration of  the  opening  of  the  prostatic  sinus  and  of  the  ejaculatory 
ducts.  As  a  result  of  this  infiltration  of  the  subepithelial  tissues,  a 
catarrhal,  often  a  suppurative,  process  is  set  up  both  on  the  urethral 
surface  and  in  the  prostatic  glands  and  their  ducts. 

Symptoms. — The  prostatic  and  membranous  portions  of  the  urethra 
are  usually  involved  in  cases  of  acute  urethritis.  This  involvement  is 
often  so  slight  that  it  occasions  no  symptoms,  not  even  undue  fre- 
quency of  urination,  and   is  detected  only  by  finding  pus  and  the 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     155 

comma-shreds  in  the  urine  which  has  been  evacuated  after  the  ante- 
rior urethra  has  been  thoroughly  flushed  by  irrigation. 

This  chronic  indolent  catarrh  is  rendered  subacute  or  even  acute 
by  very  slight  causes,  such  as  exposure  to  cold,  moderate  drinking,  or 
coitus.  The  inflammation  then  extends  forward  to  the  bulbous  urethra, 
and  there  is  a  more  or  less  free  discharge,  often  associated  with  slight 
urgency  and  undue  frequency  in  micturition.  These  symptoms  sub- 
side quickly,  and  are  usually  attributed  to  a  mild  cystitis. 

The  anterior  discharge  disappears,  and  the  patient  considers  him- 
self well  till  some  further  imprudence  causes  these  symptoms  to 
recur. 

When  the  inflammation  extends  deeper,  involving  the  mucous 
membrane  of  the  caput  gallinaginis  and  the  glandular  and  periglandular 
structure  of  the  prostate,  the  symptoms  usually  become  very  pro- 
nounced. The  nerve-supply  of  this  region  is  exceedingly  rich,  and  its 
relation  to  the  genital  system  is  so  close  that  any  decided  change  in 
the  structure  of  the  prostate  is  necessarily  attended  by  well-marked 
local  and  general  symptoms. 

Tenesmus  is  perhaps  the  most  frequent  local  symptom  observed. 
This  may  appear  simply  in  the  form  of  increased  frequency  of  mictu- 
rition, or  it  may  force  the  patient  to  make  several  efforts  at  urination, 
passing  a  small  quantity  each  time  before  the  sensation  is  relieved. 
The  passage  of  hardened  fseces,  the  pressure  of  the  examining  finger 
through  the  rectum,  or  the  excitement  of  coitus  may  all  occasion  an 
intense  desire  to  urinate. 

Pain  may  be  a  pronounced  feature  in  these  cases.  At  times  it  is 
constant,  deep-seated,  burning,  stinging,  and  peculiarly  harassing.  It 
sometimes  radiates  to  the  rectum  and  down  the  thighs,  and  is  often 
greatly  exaggerated  by  sexual  intercourse. 

Sexual  weakness  is  a  not  infrequent  sequel  of  chronic  posterior 
urethritis.  '  It  may  take  the  form  of  pollutions,  hnpotence,  prostator- 
rhoea,  or  rarely  true  spermatorrhoea. 

Sexual  neurasthenia  is  an  almost  invariable  accompaniment  of 
the  deeper-seated  chronic  inflammation  of  the  posterior  urethra. 

Diagnosis. — This  is  founded  on  (1)  the  repeated  recurrence  of 
purulent  discharge  after  apparent  cure  and  from  seemingly  insuf- 
ficient causes  ;  2,  clap-shreds  in  the  second  urine  or  the  presence  of 
unstained  shreds  in  the  urine  passed  after  irrigation  of  the  anterior 
urethra  with  staining  solutions,  such  as  methyl  blue ;  3,  attacks  of 
epididymitis,  so-called  cystitis,  and  prostatitis ;  4,  frequency  and  ur- 
gency of  urination,  either  constant  or  paroxysmal ;  5,  symptoms  of 
sexual  neurasthenia. 


156  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

The  differential  diagnosis  between  chronic  anterior  urethritis  and 
CHRONIC  posterior  URETHRITIS  may  be  summarized  as  follows  (Finger) : 

Discharge  from  Meatus. — In  comparatively  recent  cases  of  chronic 
anterior  urethritis  there  is  either  a  constant  or  a  morning  muco-puru- 
lent  discharge.  In  old  cases  there  is  simply  a  constant  or  usually  only 
a  morning  gluing  of  the  lips  of  the  meatus,  or  there  may  be  no  per- 
ceptible discharge. 

Chronic  posterior  urethritis  gives  no  discharge  from  the  meatus. 

Test  of  the  Tico  Beakers. — Chronic  anterior  urethritis  causes  the 
first  portion  of  urine  to  exhibit  shreds  and  often  slight  cloudiness. 

Chronic  posterior  urethritis  if  comparatively  recent  makes  both 
urines  slightly  cloudy, — the  first  containing  the  ordinary  stringy  clap- 
shreds,  the  second  often  exhibiting  Fiirbringer's  hooks  (short,  dense, 
comma-shreds,  supposed  to  represent  plugs  from  folKcles  or  gland- 
ducts).  Long-standing  chronic  urethritis  does  not  cause  cloudiness- 
of  the  urine,  but  causes  shreds  to  appear  always  in  the  first  portion 
passed,  often  in  both  portions. 

Test  of  the  Two  Beakers  after  Irrigation  of  the  Anterior  Urethra.— 
In  chronic  anterior  urethritis  both  urines  are  clear. 

In  chronic  posterior  urethritis  the  appearance  of  the  urine  is  the 
same  as  though  the  anterior  urethra  had  not  been  irrigated, — i.e.,  as 
in  the  test  of  the  two  beakers. 

In  chronic  anterior  urethritis  the  urethrameters  or  acorn  bougies 
will  show  in  old  cases  certain  points  of  lessened  dilatability.  There 
will  be  no  other  symptoms,  while  in  chronic  posterior  urethritis  there- 
are  often  tenesmus,  prostatorrhoea,  frequent  micturition,  spermator- 
rhoea, sexual  irritation,  increased  desire,  frequent  pollutions,  pre- 
cipitate, often  painful,  ejaculation,  feeble  erection,  impotence,  and 
neurasthenia. 

Prognosis. — The  great  majority  of  cases  of  posterior  urethritis 
recover  without  direct  treatment.  It  is,  however,  a  rule  with  few 
exceptions  that  a  gleet  cannot  be  permanently  cured  as  long  as  there 
persists  a  chronic  inflammation  of  the  posterior  urethra,  and  where 
chronic  urethral  discharge  is  not  due  to  the  presence  of  well-developed 
stricture  its  dependence  upon  posterior  urethritis  must  always  be 
suspected.  In  some  cases  without  treatment  the  inflammation  lasts 
indefinitely,  extending  gradually  deeper  till  irreparable  damage  has 
been  done  to  the  structure  of  the  prostate  or  the  ejaculatory  ducts 
have  become  permanently  blocked.  At  times  the  chronic  inflamma- 
tion seems  to  be  the  exciting  cause  for  the  development  of  genito- 
urinary tuberculosis. 

Treatment. — The  general  hygienic  and  dietetic  rules  laid  down  in 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     157 


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158  GENITO-UKINARY    DISEASES   AND   SYPHILIS. 

the  systematic  treatment  of  acute  urethritis  should  be  enforced, 
though  moderate  indulgence  in  light  wines  during  meals  need  not  be 
forbidden  unless  liquors  of  all  kinds  are  contra-indicated  for  other 
reasons.  A  sound  digestion  and  regular  movements  of  the  bowels 
are  particularly  to  be  insisted  on. 

Balsams  and  antiseptics,  such  as  copaiba,  oil  of  sandal  wood,  and 
extract  of  saw  palmetto  should  be  administered  by  the  mouth  in  doses 
not  sufficient  to  disturb  the  stomach.  The  urine  should  be  rendered 
bland  and  unirritating.  Copious  hot  rectal  douches  will  prove  useful 
when  bladder  irritability  or  sexual  neuroses  are  marked.  Massage  of 
the  prostate  is  of  value  in  long-standing  cases.  For  the  direct  treat- 
ment there  may  be  used  irrigations,  sounds,  instillations,  and  oint- 
ments or  suppositories. 

Irrigation  of  the  prostatic  urethra  should  be  preceded  every  third 
day  by  prostatic  massage,  since  thus  the  crypts  and  follicles  are  emptied 
and  are  subject  to  the  subsequent  cleansing  wash.  Irrigation  is  prac- 
tised by  means  of  the  short  urethral  nozzle  and  irrigating  bag.  Excep- 
tionally the  pressure  necessary  to  overcome  the  resistance  of  the 
compressor  urethree  muscle  is  painful  and  irritating  to  the  anterior 
urethra.  A  soft  rubber  catheter  may  then  be  used,  or,  if  the  spas- 
modic action  of  the  sphincter  is  too  strong  to  allow  the  introduction 
of  this  instrument,  an  ordinary  Enghsh  catheter.  This  instrument 
is  passed  till  its  end  is  within  the  grip  of  the  compressor  urethras 
muscle ;  then  a  hard  rubber  syringe  is  employed  to  throw  in  two 
ounces  of  a  dilute  antiseptic  solution,  such  as  1  to  1000  argyrol 
or  1  to  2000  protargol,  or  1  to  5000  potassium  permanganate,  or 
1  to  1000  ichthyol,  or  a  lotion  representing  corrosive  sublimate  1  to 
10,000,  with  carbolic  acid  1  to  200.  This  flows  back  into  the 
bladder.  The  catheter  is  then  withdrawn  until,  the  injection  being 
continued,  the  fluid  flows  .out  from  the  meatus,  when  it  is  attached  to 
a  fountain  syringe  containing  one  or  two  pints  of  a  hot  dilute  anti- 
septic solution,  and  the  anterior  urethra  is  flushed  thoroughly,  the 
whole  contents  of  the  bag  being  employed  at  each  treatment.  This 
injection  may  be  accomplished  without  the  intervention  of  the  piston 
syringe,  the  catheter  being  attached  directly  to  the  irrigator  introduced 
into  the  bladder  and  very  slowly  withdrawn  after  the  stream  is  turned 
on  until  the  back-flow  escapes  from  the  meatus.  These  treatments 
are  repeated  every  day  for  two  weeks,  or  until  clap-shreds  disappear 
from  the  urine,  then  every  second  or  third  day,  being  thus  stopped 
gradually.  When  a  given  solution  occasions  dislinct  vesical  irrita- 
bility and  increased  urethral  discharge,  it  should  be  weakened  or 
changed.     If  it  is  well  borne,  it  is  gradually  increased  in  strength  up 


AFFECTIONS  CHAKACTERIZED  BY  URETHRAL  DISCHARGE.     159 

to  1  to  4000  bichloride,  1  to  500  protargol,  or  1  to  1000  permanganate. 
Every  third  day,  immediately  preceding  irrigation,  a  full-sized  sound 
is  passed. 

If,  after  two  or  three  weeks  of  these  massages  and  irrigations  or 
injections,  the  posterior  catarrh  continues,  and  particularly  if  there 
are  some  tenesmus  and  undue  frequency  of  urination,  the  posterior 
irrigations  are  supplanted  by  instillations. 

Instillations  are  made  by  means  of  a  long  catheter-nozzled  syringe 
called  an  instillator.  (Fig.  61.)  This  is  a  hard  rubber  or  silver 
catheter,  cylindrical  in  shape,  eight  inches  long,  provided  with  a  short 


Fig.  61. 


Instillator. 


terminal  curve,  and  having  an  extremely  fme  central  channel.  To  the 
straight  end  of  this  catheter  is  secured  an  ordinary  hypodermic  syringe. 
The  cross-bar  at  the  top  not  only  facilitates  injection,  but  indicates 
the  position  of  the  curved  end  of  the  instrument.  Five  to  twenty 
drops  of  the  solution  desired  are  sucked  up  into  the  syringe  through 
the  fme  central  tube  of  this  catheter;  the  latter  is  lubricated,  and  is 
inserted  until  its  end  lies  just  within  the  grip  of  the  compressor 
urethrse  muscle.  The  solution  is  then  driven  in  by  pressure  upon  the 
piston  of  the  syringe,  and  flows  backward  along  the  membranous  and 
prostatic  urethra  into  the  bladder.  If  these  injections  are  properly 
made,  not  a  drop  escapes  into  the  anterior  urethra. 

These  instillations  require  that  the  extremity  of  the  instrument 
shall  be  carried  exactly  to  the  proper  point, — i.e.,  just  within  the  mem- 
branous urethra.  Usually  it  is  easy  to  determine  this  point.  It  lies 
over  five  inches  and  under  seven  inches  from  the  meatus,  and  is 
reached  only  when  the  shaft  of  the  instrument  is  swept  vertically 
upward  from  the  belly  wall  and  is  carried  downward  between  the 
legs  till  it  makes  an  angle  of  about  seventy  degrees  with  the  plane 
of  the  horizon.  The  compressor  urethras,  at.  first  resisting  the 
passage  of  the  instrument,  on  steady  pressure  rather  suddenly  yields, 
letting  the  extremity  easily  slip  farther.  Moreover  the  patient  is 
aware  of  this  sensation  of  yielding,  and  can  notify  the  surgeon  when 
it  is  felt,  though  by  the  former  it  may  be  wrongly  attributed  to  the 
instrument  entering  the  bladder.  Often  at  the  moment  the  end  of 
the  instrument  passes  within  the  grip  of  the  compressor  it  causes  a 
violent  desire  to  urinate,  though  the  sensation  is  more  commonly 


160  GEXITO-UKIXARY   DISEASES   AND   SYPHILIS. 

associated  with  irritation  of  the  prostatic  urethra,  and  is  immediately 
excited  often  to  a  most  distressing  degree  when,  after  properly  passing 
the  instillator,  the  strong  injection  is  driven  in. 

Exceptionally  it  is  extremely  difficult  to  determine  just  when  the 
instillator  catheter  has  been  introduced  to  the  proper  depth.  Thus 
the  distance  guide  (five  and  a  half  to  seven  inches)  may  fail  in  cases  in 
which  the  introduction  of  the  instrument  causes  a  condition  of  partial 
erection,  or  when  the  penis  varies  greatly  from  the  normal  extremes 
of  size.  The  resistance  of  the  accelerator  urinas  may  be  mistaken 
for  that  of  the  compressor  urethrae ;  this  mistake  will  be  avoided 
if  it  is  remembered  that  the  resistance  of  the  accelerator  urinse  is 
always  encountered  less  than  five  inches  from  the  meatus  and  usually 
less  than  four  inches.  The  compressor  urethrae  may  offer  such  shght 
resistance  that  it  is  not  perceptible  to  the  hand  passing  the  instrument, 
or,  if  in  a  condition  of  reflex  irritability  and  if  associated  with  a  capa- 
cious bulb,  may  resist  so  tightly  as  to  prevent  the  engagement  of  the 
point  of  the  instrument,  which,  when  the  handle  is  swept  between  the 
thighs,  ghdes  upward,  yielding  a  false  sense  of  progression  and  lead- 
ing to  injection  into  the  anterior  urethra.  These  mistakes  may  be 
avoided  by  measuring  the  distance  from. the  meatus  to  the  compressor 
by  means  of  a  full-sized  bulbous  bougie  and  marking  this  distance 
on  the  shaft  of  the  mstillator.  In  the  absence  of  the  sense  of  yielding 
usually  experienced  when  the  end  of  the  instrument  is  held  firmly 
against  the  compressor  urethrae  muscle,  the  instrument  should  be 
passed  until  its  point  is  fixed, — i.e.,  cannot  be  rotated  from  side  to  side, 
when  the  convexity  of  the  curve  is  prevented  from  rocking  by  external 
pressure  made  by  the  fingers  on  the  perineum. 

The  solutions  employed  in  the  instillation  treatment  are  those  of 
silver  nitrate,  copper  sulphate,  protargol,  iodine  and  carbolic  acid,  and 
bichloride  of  mercury.  The  stronger  the  solution  the  fewer  the  number 
of  drops  to  be  employed. 

The  most  valuable  of  all  solutions  in  the  treatment  of  chronic 
gonorrhoeal  urethritis  is  silver  nitrate,  beginning  with  ten  drops  of  a 
one  per  cent,  solution,  repeating  the  application  every  third  day,  and 
running  the  strength  up  to  five  or  even  ten  per  cent.  These  instilla- 
tions usuahy  should  be  preceded  by  the  passage  of  a  full-sized  sound 
and  by  an  irrigation.  Copper  sulphate  or  iodine  and  carbolic  acid, 
equal  parts  of  one  per  cent,  to  ten  per  cent,  solution,  may  be  employed 
when  silver  nitrate  is  either  inetfective  or  is  followed  by  an  undue 
amount  of  bladder  irritability.  In  making  these  injections  the  bladder 
should  contain  a  small  quantity,  of  urine,  since  thus  any  portion  of  the 
medicament  which  passes  into  its  cavity  will  be  at  once  diluted  and. 


AFFECTIONS  CHAKACTERIZED   BY  UKETHRAL  DISCHARGE.    IQl 

in  the  case  of  silver  nitrate,  neutralized.  If  the  bladder  is  largely  dis- 
tended with  urine,  the  medicament  is  diluted  before  it  has  thoroughly 
acted  upon  the  whole  of  the  prostatic  urethra. 

Instillations  are  particularly  indicated  when  in  addition  to  the 
discharge  from  the  posterior  urethra  there  are  frequent  or  urgent 
urination,  pollutions,  pain  during  orgasms,  constant  or  intermittent 
pain  in  tlie  deep  urethra,  or  any  of  the  symptoms  denoting  deep- 
seated  involvement  of  the  prostatic  urethra.  Instillations  are  contra- 
indicated  when  the  symptoms  are  acute  in  type  ;  when  examination 
of  the  urine  shows  that  the  discharge  is  profuse ;  when  examination 
through  the  rectum  indicates  acute  inflammation  of  the  seminal 
vesicles ;  when  even  the  weaker  instillation  lotions  are  followed  by 
prolonged  perineal  pain,  distressing  tenesmus  and  frequency  of  urina- 
tion, fever,  pain  in  the  testicles,  or  the  discharge  of  blood  at  the  end 
of  urination.  In  tubercular  cases  the  silver  nitrate  markedly  aggra- 
vates the  severity  of  the  symptoms,  this  bad  effect  continuing  for  many 
days. 

The  effect  of  the  instillation  seems  to  be  the  substitution  of  an 
acute  urethral  inflammation  for  one  which  has  become  chronic  and 
deep-seated,  thus  producing  a  condition  of  hyperaemia  and  of  alDun- 
dant  exudate,  followed  by  active  processes  of  absorption  of  both  the 
new  and  the  old  inflammatory  exudates  and  a  return  to  normal  con- 
ditions. Occasionally  they  will  relieve  almost  instantly  the  distressing 
tenesmus  of  acute  urethritis. 

A  mixture  of  iodine  and  carbolic  acid,  equal  parts  of  each,  is  of 
service  in  inveterate  chronic  cases  so  sluggish  that  the  stronger  silver 
solution  seems  to  have  no  effect. 

Ointments,  especially  those  made  with  lanolin  as  an  excipient,  are 
particularly  commended  by  Finger  as  being  more  penetrating  and 
more  lasting  in  their  effect  than  lotions.  Ointments  may  be  applied 
to  the  whole  urethra  by  means  of  the  sounds  proposed  by  Unna. 
These  are  coated  with  the  following  mixture  : 

R   01.  theobrom.,   §i; 
Cerse  flav.,  gr.  x  ; 
Argenti  nit.,  gr.  v  ; 
Bals.  Peruvian.,  gr.  x. 
M.     S. — Melt  over  a  water  bath. 

The  sounds  are  covered  with  this  ointment  while  it  is  warm,  and 
are  then  hung  in  the  air  to  cool  and  to  allow  of  solidiflcation  of  the 
ointment.  When  the  sound  thus  coated  is  introduced  into  the  urethra 
the  heat  of  the  parts  melts  the  ointment,  and  thus  the  entire  mucous 

11 


162 


GENITO-UEINART   DISEASES   AND   SYPHILIS. 


membrane  is  medicated. 


In  chronic  cases  associated  with  catarrh  of 
the  whole  urethra  this  treatment  is  of 
value,  since  the  effect  of  medication 
is  enhanced  by  the  pressure  of  the 
sound. 

Ointments  may  be  applied  to  the 
posterior  urethra  alone  or  to  localized 
inflammations  of  the  anterior  urethra 
by  a  piston  catheter  so  designed  that 
the  lumen  of  the  instrument  can  be 
partly  filled  with  the  melted  ointment, 
when  by  pushing  the  piston  down  as 
much  as  is  desired  can  be  forced  out 
from  the  open  end.  By  making  the 
.lumen  of  the  catheter  of  a  given  diam- 
eter and  by  proper  markings  on  the 
staff  of  the  piston,  the  exact  quantity 
of  ointment  deposited  on  any  portion 
of  the  urethra  may  be  known.  The 
instrument  of  Tommasoli  is  among  the 
best.     (Fig.  62.) 

The  ointments  of  choice  are : 

R    Creolin,  n:\,v  to  v\xv  ; 
Lanolin,   §i; 
01.  olivse,   gss. 

Silver  nitrate  or  copper  sulphate, 

five  to  fifteen  grains,  may  replace  the 

creolin  in  this  formula. 

Or 

li    Potassii  iodidi,  ;^ss  ; 

lodi  pur.,  gr.  v  ; 

Lanolin,  3  i  ; 

01.  olivEe,  gss, 
or 

R    Ammon.  sulph.  ichthyolat.,  gr.  xlviii  ; 
Lanolin,  31, 


may  be  used. 

The  application  of  these  ointments 
should  follow  the  passage  of  a  full- 
sized  sound. 
Suppositories  may  be  made  of  either  gelatin  or  cacao  butter.     They 


Tommasoli's  ointment-carrier. 


AFFECTIONS  CHARACTERIZED  RY  URETHRAL  DISCHARGE,     igo 

are  introduced  by  means  of  an  instrument  very  like  that  employed 
for  the  application  of  ointments,  except  that  the  piston  forms  a  close- 
fitting  obturator  for  the  introduction.  This  catheter  is  passed  until 
the  end  has  engaged  in  the  grasp  of  the  compressor  urethree  muscle ; 
the  obturator  is  then  withdrawn,  and  a  suppository  introduced  within 
the  lumen  of  the  catheter  and  pushed  into  the  prostatic  urethra  by 
means  of  the  obturator.  The  medications  of  choice  are  practically 
those  already  given,  silver  nitrate  being  particularly  serviceable ; 
astringents  and  sedatives  may  also  be  administered  in  this  way. 

R  Ext.  hydi  ast.,  gr.  v  ; 
Iodoform.,  gr.  ii, 

R   Zinci  sulphalis,  gr.  i ; 
Acidi  carbolic! ,  gr.  i ; 
Morphin.  sulph.,  gr.  |- ; 
Ext.  belladonnae,  gr.  ss  ; 
Cocain.  hydrochlor.,  gr.  ss  to  gr.  i 

will  be  found  among  the  most  useful  formulae. 

These  suppositories  are  occasionally  of  service  when  the  patient 
is  compelled  to  conduct  most  of  the  treatment  himself,  since  he  can 
readily  be  instructed  as  to  the  proper  application,  and  since  they  are 
less  irritating  than  strong  instillations,  and  hence,  in  case  of  improper 
administration,  are  less  liable  to  do  harm. 

Pressure  and  cold  water  also  are  potent  means  of  influencing 
chronic  posterior  urethritis,  particularly  when  this  has  penetrated 
deeply  and  is  rebellious  to  ordinary  treatment.  The  pressure  of  a 
full-sized  sound  is  serviceable  and  usually  sufficient,  but  in  the  in- 
veterate cases  this  will  not  answer,  since  the  narrow  membranous 
urethra  does  not  allow  of  the  entrance  of  a  solid  metal  instrument 
sufficiently  large  to  dilate  the  prostatic  urethra.  Under  these  cir- 
cumstances the  prostatic  dilator  (Fig.  63)  applied  at  interva^.s  of 
from  seven  to  fourteen  days  will  be  found  useful.     This  should  be 

m  Fig.  63. 


Prostatic  dilator.  flT       ^ 

preceded  by  irrigation  and  followed  by  irrigation  and  instillation.  The 
dilatation  should  be  carried  to  not  less  than  32  F.  and  not  more  than 
50  I'.,  the  sensation  of  the  patient  being  a  fair  index  as  to  the  amount 
of  stretching  which  is  allowable.     It  should  be  gradual,  five  to  ten 


164  GENITO-URINAKY  DISEASES   AND  SYPHILIS. 

minutes  being  required  for  its  completion,  and  intermittent,  the  dilator 
being  run  up  to  34,  for  instance,  maintained  there  a  minute,  and  then 
loosened  until  the  patient  is  entirely  comfortable.  After  a  little  delay 
it  is  gradually  screwed  up  to  36,  and  again  loosened,  finally  perhaps 
38  or  40  being  reached,  but  not  if  the  pain  excited  by  slighter  dilata- 
tions is  extremely  severe. 

In  the  inveterate  cases  characterized  by  prostatorrhoea  and  the 
symptoms  of  sexual  neurasthenia,  the  psychrophore  may  be  serviceable. 
This  consists  of  a  full-sized  hollow  metal  sound  wiiich  can  be  kept  at 
any  desired  temperature  by  a  current  of  water  flowing  through  it. 

Summary  of  the  Treatment  of  Chronie  Gonorrhoea. — As  a  basis  of 
treatment  the  seats  of  inflammation  must  be  accurately  located  by 
palpation,  sounds,  bulbous  bougies,  and  the  urethroscope.  Exami- 
nation of  the  discharge  as  it  flows  from  the  meatus,  and  as  it  appears 
in  the  urine,  shows  approximately  the  inflamed  area,  indicates  the 
extent  of  follicular  involvement,  and  affords  a  means  of  determining 
whether  the  discharge  is  still  contagious. 

The  inflammation  is  more  deeply  seated  and  more  persistent  in 
the  bulb,  the  prostatic  urethra,  and  the  navicular  fossa.  It  may  be 
sharply  circumscribed,  but  more  commonly  there  is  an  extensive 
surrounding  area  of  congestion  and  catarrhal  discharge  involving 
both  the  anterior  and  the  posterior  portion  of  the  urethra. 

Where  there  is  free  secretion  containing  much  mucus  and  flat  and 
transitional  epithelium,  irrigation  is  particularly  serviceable  in  cutting 
down  discharge  and  curing  the  general  superficial  inflammation. 
The  irrigation,  always  immediately  preceded  by  urination,  should  be 
made  under  strong  pressure  (five  feet),  and  should  include  the  entire 
urethra.  Permanganate  1  to  6000  to  1000,  silver  nitrate  or  protargol 
1  to  6000  to  500,  corrosive  chloride  1  to  20,000,  zinc  sulphate,  carbolic 
acid,  powdered  alum,  of  each  twelve  grains  to  the  pint,  are  the  solutions 
of  choice,  and  should  occasionally  be  preceded  by  massage  of  the  pros- 
tate and  the  passage  of  a  dilating  instrument  or  a  full-sized  sound, 
thus  emptying  the  inflamed  follicles  and  allowing  the  cleansing  lotions 
to  reach  the  deepest  recesses  of  the  diseased  mucous  membrane. 
The  irrigation  is  repeated  daily,  the  dilatation  every  third  day.  The 
strength  of  the  solution  is  gradually  increased  as  tolerance  is  established. 

When  by  irrigation  the  inflammation  has  become  circumscribed, 
or  when  there  is  spontaneous  subsidence  of  the  general  catarrh  but 
local  lesions  persist,  direct  applications  of  stronger  astringent  and 
antiseptic  remedies  to  the  seat  of  disease  are  indicated.  These  are 
made  to  the  lesions  of  the  anterior  urethra  through  the  urethroscope, 
to  the  lesions  of  the  posterior  urethra  by  the  instillator. 


AFFECTIONS  CHARACTEEIZED  BY  URETHRAL  DISCHARGE.    265 

The  solutions  of  choice  are  silver  nitrate  one  to  ten  per  cent.,  solu- 
tion of  copper  sulphate  in  similar  strength,  or  of  iodine  and  carbolic 
acid  each  two  to  ten  per  cent,  in  glycerin.  These  applications,  which 
are  confined  strictly  to  the  diseased  areas,  are  preceded  by  the  pas- 
sage of  a  sound  and  by  irrigation,  the  solution  of  choice  being  one  of 
bichloride  of  mercury  1  to  10,000  in  carbohc  acid  1  to  200.  The 
irrigation  is  repeated  daily,  the  sounding  every  third  day. 

When  irrigations  cause  severe  and  lasting  pain  or  excite  marked 
inflammatory  reaction  in  spite  of  having  been  carefully  weakened,  or 
cannot  be  taken  by  the  patient,  injections  with  the  ordinary  piston 
syringe  may  be  used.  These  cannot  effectively  reach  the  posterior 
urethra,  and  when  this  part  of  the  urinary  passage  is  involved  must 
be  supplemented  by  instillations,  bougies,  or  ointments.  The  steel 
sounds  or  prostatic  dilator  should  supplement  injections  once  in 
three  days.  The  injections  are  given  from  four  to  six  times  daily, 
and  are  held  in  the  urethra  for  three  minutes  each  time.  The  pain 
and  tenesmus  following  vesical  sounding,  irrigation,  and  instillation 
are  best  relieved  by  opium  and  belladonna  suppositories.  The  proof 
of  cure  of  chronic  gonorrhoea  is  absence  of  clap-shreds  in  the  urine. 
Translucent,  stringy  shreds  made  up  of  mucus  and  epithelium  will 
persist  as  long  as  treatment  is  kept  up.  The  presence  of  these  alone 
indicates  cessation  of  local  treatment.  The  general  hygienic  measures 
to  be  observed  by  a  gleety  patient  are  much  the  same  as  those  described 
under  acute  gonorrhoea,  except  that  exercise  should  be  encouraged, 
and  the  taboo  upon  liquors  need  not  be  so  absolute. 

The  first  essential  to  successful  treatment  is  restoration  of  the 
urethra  to  its  normal  calibre  ;  this  frequently  necessitates  meatotomy. 

It  is  well  to  recognize  the  fact  that  certain  exceptional  cases  of 
chronic  posterior  urethritis  cannot  be  cured  by  active  treatment.  The 
source  of  discharge  is  in  these  cases  beyond  the  reach  of  antiseptics 
or  astringents,  often  in  the  ducts  or  dilatations  of  the  prostatic  glands 
or  the  prostatic  sinus,  the  ejaculatory  ducts,  the  ampulla  of  the  vas,  or 
the  seminal  vesicles.  Applications  to  the  surface  of  the  prostatic 
urethra,  if  painful,  set  up  an  acute  inflammation,  which  by  blocking 
the  ducts  and  orifices  of  already  inflamed  glands  and  follicles  may 
cause  abscess-formation.  Moreover,  frequently  repeated  irritation 
may  produce  a  chronic  inflammation  of  the  greater  part  of  the  prostatic 
mucous  membrane,  with  infiltration  and  thickening  of  the  subepithelial 
connective  tissue,  thus  greatly  aggravating  a  condition  which  the 
apphcations  are  powerless  to  help.  If  after  two  months'  treatment  of 
a  posterior  chronic  urethritis  not  associated  with  stricture  there  is  no 
very  marked  improvement,  and  particularly  if  coincidently  with  active 


l(j(j  GEiSIlTO-UKINAKY    DLSExlSE.S   AND   SYPHILLS. 

treatment  the  patient  becomes  worse,  all  applications  and  medication 
directed  to  the  urethra,  except,  perhaps,  massage  of  the  prostate, 
should  cease,  and  the  patient  should  be  given  the  hygienic  directions 
best  calculated  to  put  him  in  good  general  condition.  The  ultimate 
prognosis  under  such  circumstances  is  usually  good.  Often  apparent 
cure  quickly  follows  cessation  of  treatment. 

Gonorrhoea  of  the  male  urethra,  in  accordance  with  its  clinical 
course,  may  be  classified  as  follows  : 

1.  Mild. 

2.  Severe. 

•  3.  Neurotic  or  neuralgic. 

4.  Recurrent  or  relapsing. 

5.  Intractable. 

Mild  gonorrhcea  is  characterized  by  long  incubation,  moderate 
symptoms,  absence  of  comphcations,  and  at  times  rapid  cure,  though 
the  disease  may  be  indefinitely  prolonged.  Treatment,  both  local  and 
hygienic,  should  be  carried  out  as  faithfully  as  would  be  indicated  for 
a  more  severe  attack. 

Severe  or  virulent  gonorrhoea,  vulgarly  called  "  Russian  Clap," 
occurs  in  those  whose  urethras  are  predisposed  to  inflammation  by 
intense  congestion,  such  as  results  from  alcoholic  and  venereal  ex- 
cesses. It  is  also  observed  in  healthy  young  men,  who  have  never 
had  a  similar  infection  and  who  have  practised  ill-advised,  irritating 
injections,  in  the  hope  of  preventing  gonococcal  infection. 

The  period  of  incubation  is  short,  the  subjective  symptoms  are 
severe.  The  discharge  is  profuse  and  bloody,  marked  posterior 
urethral  involvement  occurs  early.  Blood-stained  pollutions,  ardor 
urinse,  often  retention  of  urine,  painful  erections  and  chordee,  harass 
the  patient,  who  is  still  further  weakened  by  fever  due  to  septic  ab- 
sorption. Complications  are  common  and  troublesome.  The  course 
of  the  disease  is  usually  prolonged.  Treatment  should  be  active,  and 
stringent  to  the  minutest  detail.  Rest  in  bed,  diluents,  a  milk  and 
butter-milk  diet,  hot  sitz-baths  and  regular  evacuations  from  the  bowels 
are  means  best  calculated  to  prevent  complications  and  to  hasten  cure. 

Neurotic  (or  neuralgic)  gonorrhoea  is  characterized  by  hy- 
peracute subjective  symptoms,  out  of  proportion  to  the  amount  of 
discharge.  The  irritable  cases  show  excessive  local  pain.  Injections 
and  irrigations  are  intolerable,  and  often  cause  bleeding.  Erections 
and  chordee  are  frequent.  Local  tenderness  is  severe.  For  these 
cases  full  doses  of  bromide  are  indicated.  Hyoscine  hydrobromate, 
grain  yJoi  or  Hyoscyamine  sulphate,  grain  y-J-o,  at  bedtime  will  relieve 
chordee.     Hygienic,  dietetic  and  internal  medical  treatment  must  be 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE.     167 

stringent.  Drugs  stimulating  to  the  mucous  membrane,  such  as 
copaiba,  and  cubebs,  must  be  omitted.  Local  injections  and  irri- 
gations are  contra-indicated  until  the  subsiding  stage. 

Neurotic  or  Neuralgic  Gonorrhoea  is  often  associated  with  neu- 
rasthenia or  even  melancholia ;  there  is  a  distrust  of  treatment  and 
impatience  at  the  slowness  of  rbsults,  with  a  tendency  to  try  secretly 
every  suggestion  independent  of  its  source.  The  discharge  and  local 
symptoms  may  be  mild,  but  the  disease  tends  to  become  intractable 
as  a  result  of  diversified  treatment.  Due  consideration  to  the  neuras- 
thenic element  should  be  given  in  the  management  of  these  cases. 

Relapsing  and  recurrent  gonorrhcBa,  if  not  due  to  reinfection, 
is  usually  incident  to  an  almost  symptomless  chronic  posterior  ure- 
thritis. Exceptionally,  a  gonorrhoeal  Cowperitis  or  folliculitis  is  the 
cause.  The  treatment  consists  in  finding  and  ablating  the  focus  of  the 
recurring  urethral  infection. 

Intractable  gonorrhcBa  is  always  due  to  a  persistent  lesion, 
usually  a  folliculitis  associated  after  months  and  years  with  stricture 
formation.  As  a  rule,  it  is  observed  in  persons  im-patient  of  restraint, 
who  before  complete  cure  of  an  acute  case  revert  to  the  excesses 
which  were  responsible  for  the  original  attack.  The  treatment  of 
these  cases  is  dependent  on  finding  and  eliminating  the  local  lesion. 
A  very  small  percentage  of  these  cases  is  tubercular. 


CHAPTER    IV. 

GONORRH(EA    IN    WOMEN. 

Frequency  of  the  Disease. — Leaving  aside  the  consideration  of 
harlots,  practically  all  of  whom  suffer  from  some  of  the  acute  or 
chronic  forms  of  the  disease,  gonorrhoea  attacks  a  large  number  of 
reputable  women.  The  gloomy  Noeggerath  states  that  eighty  per 
cent,  of  women  are  affected  with  latent  gonorrhoea,  while  Sanger,  of 
nineteen  hundred  and  thirty  women  coming  to  his  clinic,  found  that 
twelve  per  cent,  had  this  disease.  Young  married  women  become 
infected  because  long-standing  gleet  is  not  generally  regarded  as  a 
possible  bar  to  matrimony :  hence  men  with  chronic  urethral  discharge 
should  at  least  understand  that  the  gonococcus  may  persist  and 
maintain  its  virulence  for  years.  Gonorrhoea  in  woman  excites 
symptoms  which  even  in  their  acute  stage  may  not  be  attributed 
by  the  patient  to  any  cause  more  serious  than  a  cold,  a  strain,  or 
some  irregularity  in  her  periodical  sickness,  and  hence  treatment  is 
often  neglected. 

Seat  of  Infection. — In  women,  as  in  men,  the  urethra  is  most  fre- 
quently involved  in  the  gonorrhoeal  inflammation.  Next  in  order  of 
frequency  comes  the  mucous  membrane  of  the  cervix,  then  that  of 
the  uterus,  and  finally  that  of  the  Fallopian  tubes. 

Vaginitis,  at  least  that  directly  due  to  the  gonococcus,  is  extremely 
rare,  except  in  children,  and  possibly  in  young  women  recently  de- 
flowered. 

Vulvitis  is  not  uncommon,  and  is  often  accompanied  by  inflamma- 
tion of  the  glands  of  Bartholin. 

Contagion. — As  in  the  male,  gonorrhoea  is  acute  or  chronic. 
Though  it  is  usually  conveyed  during  sexual  intercourse,  the  possi- 
bilities of  mediate  contagion  through  bathing- water,  garments,  towels, 
etc.,  are  much  greater  in  women  than  in  men. 

In  girl  babies  the  disease  is  nearly  always  acquired  by  mediate 
contagion.  The  discharge  is  derived  som.etimes  from  a  gonorrhoeal 
ophthalmia,  generally  from  the  genital  tract  of  the  mother.  Only 
very  exceptionally  is  the  contagion  immediate  and  from  criminal 
practices. 

168      • 


GONOEEHOEA   IN    WOMEN.  169 

Acute  gonorrhoea  is  usually  acquired  from  the  discharge  of  an 
acute  case,  though  there  can  be  no  doubt  that  chronic  gonorrhoea  in 
the  male  may  excite  a  florid  attack  in  the  female.  Gleety  discharges, 
if  contagious,  sometimes  gives  rise  to  a  subacute  attack. 

Symptoms. — The  symptoms  of  acute  gonorrhoea  are  at  the  begin- 
ning usually  those  of  acute  vulvitis  and  urethritis ;  in  children  and 
young  girls  there  is  also  an  acute  vaginitis. 

The  patient  complains  of  a  sense  of  heat  and  burning  about  the 
genitalia,  of  profuse  purulent  discharge,  of  ardor  urinse,  and  of  urgency 
and  frequency  in  micturition. 

If  the  uterine  mucous  membrane  is  also  involved  there  are  usually 
marked  constitutional  symptoms,  i.e.,  fever  and  depression,  and,  in 
addition,  severe  pains  in  the  uterine  region,  swelling  of  the  womb,  and 
bloody  purulent  discharge  from  it.  Not  infrequently  perimetritis 
complicates  the  uterine  inflammation. 

The  involvement  of  the  mucous  membrane  of  the  ovarian  tubes 
may  cause  salpingitis  and  peritonitis. 

An  examination  shows  the  mucous  membrane  of  the  vulva  and 
sometimes  that  of  the  vagina  infiltrated,  reddened,  and  eroded.  Pus 
can  be  milked  from  the  urethra. 

The  subacute  gonorrhoea  sometimes  acquired  from  chronic  gonor- 
rhoea of  the  male  rarely  shows  itself  by  pronounced  typical  symptoms. 
There  are  intermittent  attacks  of  slight  ardor  urinse,  frequency  of  mic- 
turition, disorders  of  menstruation,  pelvic  pains,  and  disturbances  in 
the  uterine  function,  manifested  by  dysmenorrhoea,  by  sterihty,  by 
abortion,  and  by  attacks  of  perimetritis,  salpingitis,  ovaritis,  or  local 
or  general  peritonitis.  The  patients  gradually  lose  their  health,  be- 
come unfit  for  work  of  any  kind,  and  are  prone  to  develop  into  typical 
neurasthenics. 

On  examination  there  will  usually  be  found  a  catarrhal  condition 
of  Bartholin's  glands  and  of  the  periurethral  follicles.  Purulent  secre- 
tion escapes  from  the  cervical  canal,  which  is  sometimes  eroded.  The 
uterus  is  found  enlarged,  tender  on  pressure,  and  fixed  in  its  abnormal 
position  from  attacks  of  perimetritis.  The  ovaries  and  tubes  are  often 
enlarged,  displaced,  and  fixed. 

Diagnosis. — In  the  ordinary  acute  case  this  is  not  difficult,  since 
the  symptoms  themselves  are  almost  characteristic,  and  the  detection 
of  the  gonococcus  will  at  once  settle  the  nature  of  the  attack. 

The  subacute  form  is  sometimes  extremely  difficult  to  diagnose, 
since  the  gonococcus  may  not  be  found.  According  to  Sanger,  in 
arriving  at  such  a  diagnosis  careful  search  should  be  made  for  acute 
or  chronic  gonorrhoea  in  the  husband,  or  a  history  of  gonorrhoea  sub- 


170  GENITO-UEIISTAEY    DISEASES   AND   SYPHILIS. 

sequently  cured.     The  presence  of  gonorrhoeal  ophthalmia  in  children 
is  highly  suggestive. 

Matters  of  diagnostic  import  are  :  a  history  of  uterine  catarrh  with- 
out obvious  cause ;  disease  of  Bartholin's  glands,  and  especially  red- 
ness of  the  skin  surrounding  their  ducts ;  the  presence  of  condylo- 
mata ;  the  discharge  of  muco-purulent  matter  from  the  cervix  without 
erosions  or  pseudo-erosions  of  the  os  ;  disease  of  the  adnexa  or  of  the 
pelvic  peritoneum.  Without  doubt  many  of  these  affections  are  due 
to  other  germs  than  the  gonococcus,  such  comphcations  representing 
a  form  of  mixed  infection. 

URETHRITIS. 

The  urethra  is  nearly  always  involved  in  gonorrhoeal  infection, 
and  the  presence  of  inflammation  in  this  canal  is  in  itself  presumptive 
evidence  of  the  nature  of  the  urethritis. 

Acute  Urethritis. — The  acute  stage  of  the  disease  is  brief,  and 
is  accompanied  by  symptoms  of  moderate  severity  as  compared  with 
urethritis  in  the  male.  It  is  less  liable  to  become  chronic  than  is  the 
case  in  men,  or  if  it  lingers  it  causes  symptoms  so  slight  that  they  are 
readily  overlooked :  hence  the  frequency  of  the  involvement  of  the 
urethra  in  gonorrhoeal  inflammation  is  often  underestimated. 

Symptoms. — These  are  very  much  like  those  observed  in  men. 
The  incubation  period  varies  from  a  few  hours  to  five  or  six  days,  and 
exceptionally  is  much  longer.  Slight  tickling  or  burning  sensations 
on  urination,  moderate  purulent  discharge,  demonstrated  by  milking 
the  urethra  from  above  downward,  and  a  swollen,  cedematous 
urethral  orifice  are  often  the  only  symptoms  which  can  be  detected, 
though  in  specially  sensitive  women  there  will  be  at  the  beginning  of 
the  attack  rigors,  slight  fever,  and  general  malaise.  In  from  a  few 
days  to  two  or  three  weeks  even  these  symptoms  disappear,  and  the 
disease  is  regarded  as  cured. 

Finger  believes,  however,  that  it  becomes  chronic  in  women  much 
more  frequently  than  is  the  case  in  men,  being  subject  to  exacerbations, 
and  often  months  after  the  original  attack  exciting  a  urethro-cystitis, 
the  symptoms  and  course  of  which  are  much  like  those  of  the  same 
condition  in  man,  except  that  it  is  less  severe  and  more  amenable  to 
treatment. 

Chronic  urethritis  rarely  excites  sufliciently  characteristic  symp- 
toms to  suggest  a  probable  diagnosis  without  a  thorough  examination. 
This  should  be  conducted  at  a  time  when  the  patient  has  not  urinated 
for  several  hours.  Pressure  on  the  urethra  from  behind  forward  may 
show  that  this  tube  is  thickened  and  somewhat  sensitive,  and  will 
usually  press  out  a  thin,  milky,  muco-purulent  drop.     In  case  there 


aONOREHCEA    IN    WOMEN, 


171 


is  not  sufficient  discharge  for  this,  the  vulva  and  vagina  are  carefully 
washed  and  the  patient  is  requested  to  urinate  in  two  portions. 
Clap-shreds  and  pus  will  be  found  in  the  hrst  portion ;  if  pus  is  dis- 
covered in  the  last  portion,  this  is  usually  indicative  of  the  presence 
of  chronic  cystitis. 

x4.n  endoscopic  examination  in  cases  of  acute  urethritis  in  women 
shows  redness,  swelling,  and  general  acute  congestion  of  the  mucous 
membrane.  In  the  chronic  cases  diffuse  redness,  areas  of  epithelial 
thickening,  and  sometimes  comparatively  deep  erosions  are  observed, 
the  latter  especially  about  the  openings  of  follicles. 

Folliculitis. — As  in  the  male,  the  urethra  contains  many  follicles, 
and  these  are  subject  to  gonorrhceal  inflammation,  forming  small 
tender  tumors  Avhich  commonly  evacuate  their  contents  into  the 
urethra. 

There  are  tv\^o  follicles  which  are  particularly  liable  to  become 
infected.  These  are  situated  in  the  lower  urethral  wall  and  open  just 
within  the  external  urethral  orifice.  A  fine  probe  can  be  inserted  into 
the  duct  of  each  to  a  depth  of  from  one-half  to  three-fourths  of  an  inch. 
When  these  follicles  are  acutely  inflamed  and  their  urethral  openings 
firmly  blocked,  the  softening  and  breaking  down  may  cause  urethro- 
vestibular  or  urethro-vaginal  fistulas. 

In  addition  to  these  two  deep  follicles  there  are  a  number  of 
smaller  ones  situated  about  the  meatus.  Many  or  all  of  these  may 
become  inflamed,  rendering  the  urethral  opening  unsymmetrical. 
They  often  rupture  into  the  urethra,  but  again  fill  up  and  continue  to 
discharge  intermittently. 

The  frequency  with  which  these  follicles  are  involved  in  gonor- 
rhceal inflammation  makes  diagnosis  particularly  important.  A  care- 
ful examination  usually  shows  at  once  the  true  nature  of  the  case, 
since  immediately  after  the  urethra  has  been  washed  clean  by  the  act 
of  urination  pressure  causes  exudation  of  pus.  Moreover,  on  direct 
examination  tlie  inflamed  openings  of  the  follicles  can  generally  be 
found. 

JDiagnosis. — The  diagnosis  of  acute  urethritis  is  dependent  upon 
the  symptoms  and  on  finding  the  gonococcus. 

If  after  holding  the  water  for  several  hours  no  pus  can  be  milked 
from  the  urethra,  the  vulva  and  vagina  should  be  washed  free  of  dis- 
charge. The  patient  should  then  micturate  immediately,  and  the 
urine  should  be  carefully  examined  for  pus. 

Progno.Kts. — The  prognosis  of  urethritis  is  in  women  much  more 
favorable  than  in  men.  The  disease  lasts  for  but  a  short  time ;  the 
chronic  forms  of  it  occasion  no  trouble  and  usually  undergo  spon- 


172  GENITO-UKINAKY    DISEASES   AND   SYPHILIS. 

taneous  cure  without  producing  serious  or  permanent  alterations  in 
the  urethral  mucous  membrane. 

Treatment. — The  treatment  of  acute  urethritis  in  women  is  con- 
ducted on  the  same  principles  as  govern  the  management  of  this 
disease  in  men.  The  diet  is  regulated,  and  the  urine  is  rendered 
unirritating  by  the  administration  of  potassium  citrate  or  sodium 
bicarbonate  and  an  abundance  of  water. 

Balsams  may  be  given  from  the  first,  and  as  soon  as  the  acute 
symptoms  subside  injections  are  employed.  These  should  be  driven 
in  by  the  ordinary  clap  syringe,  but  not  more  than  a  drachm  should 
be  injected  at  one  time.  The  .  solutions  employed  are  those  used 
in  the  male  urethra,  but  may  be  slightly  stronger.  As.  soon  as  the 
acute  stage  is  past  the  lesions  are  located  by  the  urethroscope,  and  are 
treated  directly  by  means  of  iodine  two  to  ten  per  cent,  solution  in 
glycerin,  or  silver  nitrate  one  to  ten  per  cent.,  these  drugs,  of  course, 
being  applied  only  to  the  inflamed  spots  by  means  of  cotton  tampons. 

Chronic  urethritis  in  women  is  usually  dependent  upon  folliculitis, 
either  the  paraurethral  glands  about  the  meatus  or  a  group  of  follicles 
near  the  neck  of  the  bladder  being  involved.  Destruction  of  the  fol- 
licles by  a  finely  pointed  stick  of  silver  nitrate  or  the  electric  needle 
when  they  are  accessible,  or,  when  the  inflammation  is  placed  near 
the  bladder,  the  use  of  the  endoscope  for  the  application  of  iodine  or 
silver  nitrate,  is  indicated  in  these  cases. 

Exceptionally  true  stricture  forms,  usually  at  or  near  the  meatus. 
The  symptoms  are  frequent  micturition,  slight  dribbling,  and  gleet^ 
though  the  latter  is  rarely  noticed.  The  fact  that  stricture  may 
result  from  gonorrhceal  inflammation  of  the  female  urethra  would 
suggest  a  search  for  this  condition  in  cases  of  functional  urinary  diffi- 
culty in'  women.  The  diagnosis  is  readily  made  by  means  of  the 
bulbous  bougie.  Narrowing  at  or  very  near  the  meatus  may  require 
division,  the  knife  cutting  backAvard.  Gradual  dilatation  will  prove 
efficient  for  all  other  cases  not  traumatic.  Straight  metal  bougies  are 
employed  running  up  to  40  F.     (Fig.  64.) 


Fig.  64. 


Short  straight  bougie. 


There  is  one  form  of  chronic  urethritis  much  resembling  in  symp- 
toms the  posterior  urethritis  observed  in  men.  The  patient  com- 
plains of  frequent  urgent  urination,  tenesmus,  and  reflexes,  such  as 


GONOREHCEA   IN   WOMEN.  173 

vaginismus  and  backache,  and  a  general  condition  of  neurasthenia. 
On  urethroscopic  examination  tlie  mucous  membrane  at  the  neck  of 
the  bladder — i.e.,  within  the  grip  of  the  vesical  sphincter — is  found 
greatly  thickened  and  congested  or  even  fissured. 

The  treatment  consists  in  wide  dilatation  (40  to  50  F.)  and  the 
application  of  strong  solutions  of  silver  nitrate. 

VULVITIS. 

Inflammation  of  the  vulva  is  characterized  by  oedematous  swelling, 
redness,  and  erosions  affecting  the  greater  and  the  lesser  lips,  and  by  a 
profuse  purulent,  irritating,  extremely  fetid  discharge.  This  discharge 
coming  in  contact  with  the  neighboring  skin  produces  a  dermatitis, 
which  may  pass  backward  towards  the  anus  or  downward  along  the 
inner  surfaces  of  the  thighs.  There  are  constant  itching  and  burning 
about  the  vulva,  which  become  aggravated  to  severe  pain  by  walking 
or  motion  of  any  kind  involving  the  lower  half  of  the  body.  Trick- 
ling of  the  urine  over  the  abraded  surfaces  occasions  much  burning. 
Involvement  of  the  inguinal  glands  is  by  no  means  uncommon. 

Usually  vulvitis  has  a  tendency  to  spontaneous  recovery.  Occa- 
sionally, especially  in  children,  it  becomes  chronic,  persisting  in  the 
vestibular  glands,  and  not  only  in  those  about  the  urethra,  but  also  in 
those  placed  at  the  inner  surface  of  the  lesser  lips.  These  chronically 
inflamed  glands  cause  practically  no  symptoms,  and  are  detected  only 
by  direct  examination.  Hypersemic  or  eroded  spots  may  be  found 
overlying  the  swollen  glands,  which  can  sometimes  be  felt  as  small 
nodules  ;  condylomata  are  frequently  observed. 

Treatment. — Cleanliness  will  usually  accomplish  cure,  which  is 
hastened  by  the  employment  of  antiseptic  and  astringent  lotions  and 
by  protecting  inflamed  surfaces  from  contact  with  the  urine.  In  the 
acute  stages  the  treatment  consists  in  irrigation  with  very  hot  saline 
solution  containing  1  to  6000  bichloride  of  mercury,  practised  twice 
a  day,  or  more  frequently  if  the  discharge  is  free.  Each  irrigation  is 
followed  by  the  insertion  between  the  greater  and  the  lesser  lip 
on  each  side  of  a  thin  sheet  of  cotton  dipped  in  dilute  lead  water. 
This  cotton  should  be  changed  every  two  or  three  hours.  As  the 
symptoms  subside  the  inflamed  parts  should  be  painted  once  daily 
with  a  one  per  cent,  solution  of  silver  nitrate,  and  the  irrigation  should 
be  followed  by  the  use  of  a  cleansing  and  astringent  dusting  powder 
and  dry  cotton. 

BARTHOLINITIS. 

Inflammation  of  Bartholin's  glands  is  perhaps  the  most  frequent 
complication  of  vulvitis,  though  even  this  is  exceptional.     It  may  be 


174  GENITO-ITHINARY   DISEASES   AND   SYPHILIS. 

either  acute  or  chronic  Whetlier  it  bo  duo  to  infection  of  these 
glands  by  gonococci  or  by  the  ordinary  pus  microbes,  the  chnical 
fact  remains  that  it  is  so  rarely  associated  with  non-gonorrhoeal  forms 
of  vulvitis  that  if  it  occurs  it  is  almost  pathognomonic  of  gonorrhoea. 

Acute  Bartholinitis. — i\.cute  inflammation  of  these  glands  de- 
velops suddenly,  either  during  the  fulminant  stage  of  acute  clap  or 
long  afterwards,  from  lighting  up  of  the  chronic  inflammation  by 
sexual  excess  or  other  cause. 

There  appears  in  the  posterior  third  of  the  greater  lip,  usually  on 
one  side  alone,  though  sometimes  on  each  side,  a  tender,  hard,  very 
clearly  outlined  tumor  about  the  size  of  a  hazel-nut.  This  is  soon 
followed  by  an  oedematous  swelling  of  the  greater  lip,  sometimes  ex- 
tending to  the  lesser  lip,  and  often  as  far  forward  as  the  prepuce  of 
the  clitoris.  In  place  of  a  distinctly  outlined  tumor  there  develops  a 
dense  inflammatory  infiltration,  forming  an  extremely  tender,  painful 
swelling,  often  as  large  as  a  pigeon's  egg,  the  surface  of  which  is  red. 
Shortly  fluctuation  is  detected,  suppuration  being  denoted  at  the  same 
time  by  the  constitutional  symptoms  of  pus-formation. 

The  pus  may  break  through  the  capsule  of  the  gland,  the  over- 
lying skin  remaining  intact.  In  this  case  it  is  apt  to  burrow  backward 
along  the  perineum,  forming  extensive  sinuses,  and  even  opening  into 
the  rectum.  Usually  the  skin  also  ulcerates  and  the  pus  is  evacuated 
on  the  inner  surface  of  the  greater  lip.  This  pus  is  blood-stained  and 
foul-smelling. 

Chronic  Bartholinitis. — Chronic  inflammation  of  Bartholin's 
glands  may  appear  as  an  inflammation  of  the  gland-ducts  alone,  the 
most  frequent  form,  or  may  involve  the  gland  substance.  In  the  latter 
case  hard  nodules  are  felt  on  palpation,  and  on  pressure  a  purulent 
fluid  containing  gonococci  can  be  forced  from  the  ducts.  When  the 
ducts  alone  are  infected  no  induration  will  be  felt  on  palpation,  and 
on  inspection  nothing  is  seen  except  an  area  of  hypersemic,  or  possibly 
eroded,  mucous  membrane  around  the  duct  opening.  Pressure  may 
cause  a  small  drop  of  purulent  fluid  to  exude.  Sometimes  a  large  quan- 
tity of  this  fluid  can  be  squeezed  out,  owing  to  retention  from  blocking 
of  the  duct.  Not  infrequently  this  duct  is  the  only  mucous  surface  in 
which  the  gonococci  still  survive  :  hence  in  an  examination  to  confirm 
the  presence  or  the  absence  of  gonorrhoea  the  condition  of  Bartholin's 
glands  and  their  ducts  must  always  be  most  carefully  investigated. 

Treatment. — The  treatment  of  the  acute  inflammation  in  the  early 
stages  before  there  is  pus-formation  consists  in  putting  the  patient  to 
.  bed,  keeping  the  bowels  open,  and  applying  evaporating  lotions,  con- 
stantly renewed.     Of  these,  lead  water  and  dilute  alcohol  are  perhaps 


GONORRHEA   IN   WOMEN.  I75 

the  best.  As  soon  as  fluctuation  is  detected,  or  when  the  constitu- 
tional symptoms  denote  pus-formation,  the  pus  should  be  evacuated 
by  a  free  incision  made  on  the  inner  surface  of  the  greater  lip.  The 
cavity  should  be  curetted,  washed  with  1  to  1000  bichloride  solution, 
and  packed  with  iodoform  gauze.  This  packing  must  be  repeated 
frequently,  and  the  cavity  must  be  made  to  heal  from  the  bottom. 

Chronic  inflammation  is  extremely  difficult  to  cure.  When  the 
gland  is  involved  and  appears  as  a  hard,  slightly  tender,  circumscribed 
tumor  subject  to  occasional  attacks  of  subacute  inflammation,  the 
whole  gland  should  be  dissected  out.  If  the  ducts  alone  are  involved, 
the  catarrhal  process  may  be  cured  by  astringent  and  antiseptic  injec- 
tions carried  in  by  means  of  a  hypodermic  needle  blunted  at  the  end. 
Usually,  however,  it  will  be  necessary  to  split  the  duct  thoroughly, 
scrape  it,  and  pack  with  iodoform  gauze  until  healing  takes  place. 

METRITIS. 

Acute  metritis  develops  in  the  course  of  acute  urethritis,  vulvitis, 
or  vaginitis.  It  is  characterized  by  rigors  and  fever,  pain  in  the  hypo- 
gastric and  sacral  regions,  generally  aggravated  by  motion,  and  a  dis- 
charge from  the  cervix,  at  first  muco-purulent,  then  frankly  purulent. 
On  examination  the  womb  is  found  to  be  tender  and  enlarged,  and  the 
cervix  is  swollen,  oedematous,  and  often  eroded. 

The  inflammation  may  be  hmited  to  the  cervical  mucous  mem- 
brane. More  commonly  it  involves  the  entire  endometrium,  and  it 
may  extend  to  the  perimetrium,  tubes,  ovaries,  and  peritoneum. 

Diagnosis. — The  diagnosis  is  founded  on  the  coexistence  of  ureth- 
ritis, bartholinitis,  etc.,  and  on  the  discovery  of  the  gonococcus. 

Prognosis. — -.The  prognosis  as  to  complete  cure  must  be  guarded, 
since  the  disease  has  a  tendency  after  subsidence  of  acute  symptoms 
to  linger  indefinitely. 

Chronic  metritis,  according  to  Finger,  is  acquired  from  the  dis- 
charges of  a  chronic  gonorrhoea  of  the  urethra  or  external  genitalia  of 
the  woman,  the  uterus  having  escaped  during  the  acute  stage  of  the 
disease,  or  is  implanted  by  a  male  suffering  from  gleet.  This  form  of 
metritis  is  the  one  commonly  observed  in  young  married  women 
infected  by  their  husbands. 

Symptoms. — The  inflammation  is  ushered  in  by  a  muco-purulent 
discharge,  which  excites  little  attention,  since  it  is  attributed  to  cold, 
defloration,  excess,  or  other  apparently  sufficient  cause.  The  discharge 
becomes  profuse  at  times,  and  is  especially  free  after  the  menstrual 
])eriod.  Gradually  menstruation  becomes  painful  and  irregular  and 
the  flow  is  scanty ;  at  the  same  time  there  is  a  deterioration  in  general 


176  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

health,  with  a  sense  of  weight  and  dragging  about  the  uterus,  and  the 
patient  becomes  neurotic  and  unfit  for  work. 

The  course  of  the  chronic  inflammation  is  varied  by  intercurrent 
subacute  attacks,  somewhat  simulating  acute  metritis. 

On  examination  a  swollen,  tender  uterus  is  found,  from  which  h 
discharged  muco-pus.  The  gonococci  can  rarely  be  discovered  in 
this  discharge. 

Diagnosis. — The  diagnosis  of  chronic  gonorrhoeal  metritis  is  ex- 
tremely difficult.  A  preceding  history  of  acute  gonorrhoea,  a  venereal 
record  on  the  part  of  the  husband,  or  infection  of  others  by  the 
discharges,  would  strongly  suggest  the  causative  agency  of  the  gono- 
coccus  in  producing  this  inflammation. 

Prognosis. — This  form  of  inflammation  has  little  tendency  towards 
spontaneous  cure  ;  rather  it  extends  slowly,  particularly  in  the  direction 
of  the  tubes  and  ovaries,  producing  sterility  and  chronic  invalidism, 
and  in  many  cases  ultimately  destroying  life. 

Gonorrhoeal  salpingitis  and  oophoritis — an  extension  of  the 
gonorrhoeal  inflammation  to  the  tubes  and  ovaries — is  not  charac- 
terized by  any  pathognomonic  symptoms.  Menstruation  is  usually 
irregular,  profuse,  and  very  painful,  intercurrent  attacks  of  pelvic 
peritonitis  occur,  and  there  is  often  a  rapid  loss  of  health.  AU  these 
symptoms  are  also  observed  in  endometritis. 

The  tubes  may  be  filled  with  pus,  and  this  pus  may  escape  into 
the  uterus  or  may  make  a  way  for  itself  into  the  bowel,  the  case  thus 
recovering  spontaneously,  or  it  may  ulcerate  through  the  tube  or 
escape  by  its  fimbriated  extremity  and  occasion  a  fulminant  form  of 
peritonitis. 

With  involvement  and  obliteration  of  the  tubes  .the  ovaries  are 
nearly  always  diseased,  first  a  parovaritis  developing,  followed  by 
atrophy  and  cyst-formation  of  the  ovary. 

Diagnosis. — The  diagnosis  of  gonorrhoeal  salpingitis  and  ovaritis 
must  be  founded  on  bimanual  examination,  preferably  with  the  patient 
well  relaxed  by  ether. 

Perimetritis. — The  acute  form  of  perimetritis  is  more  prone  to 
develop  during  pregnancy  or  after  childbirth.  The  symptoms  are 
those  of  acute  pelvic  peritonitis  and  septic  absorption, — i.e.,  pain,  ten- 
derness, vomiting,  and  fever, — and  may  terminate  fatally  in  a  few 
days.  More  commonly  resolution  takes  place,  even  though  there  is 
apparently  a  large  exudate.  This  Sanger  considers  typical  of  gonor- 
rhoeal infection. 

The  recurring  form  of  perimetritis  is  due  to  pus-tubes  ;  the  symp- 
toms are  those  of.  acute  local  peritonitis,  and  are  most  severe  and  last- 


GONORRHCEA  IN   WOMEN.  ]77 

ing  during  the  first  attack.     In  the  intervals  the  woman  may  enjoy 
perfect  health. 

The  chronic  form  is  characterized  by  persistent  pain  and  tender- 
ness. Every  strain  or  jar  is  unbearable,  coitus  is  not  possible,  and 
there  is  usually  a  marked  condition  of  neurasthenia. 

Treatment. — Gonorrhoeal  cervical  endometritis  should  be  treated 
first  by  thoroughly  cleansing  the  vagina  with  antiseptic  douches,  1  to 
2000  bichloride  (hot).  The  cervix  is  then  exposed  and  its  endo- 
metrium cleared  of  the  viscid  mucus  which  coats  its  surface  by  means 
of  cotton  tampons.  Finally,  the  whole  diseased  surface  is  touched 
with  one  of  the  following  solutions,  named  in  the  order  of  their  effi- 
ciency :  1,  silver  nitrate  ten  per  cent. ;  2,  tincture  of  iodine  ;  3,  copper 
sulphate  ten  per  cent. 

Small  cysts  found  in  this  form  of  inflammation  should  be  punctured, 
and  when  there  is  marked  congestion  local  depletion  is  indicated,  the 
cervix  being  scarified  by  means  of  a  long-handled  knife. 

When  the  inflammation  resists  these  milder  forms  of  treatment, 
a  thorough  curetting,  followed  by  the  application  of  zinc  chloride, 
twenty  per  cent,  solution,  and  by  packing  with  iodoform  gauze,  will 
be  indicated. 

Endometritis  involving  the  body  of  the  womb  should  receive  no 
direct  treatment  during  the  acute  stage.  Rest  in  bed,  local  depletion 
from  the  cervix,  free  action  on  the  bowels  by  salines,  and,  when  pain 
is  very  intense,  the  administration  of  an  anodyne,  represent  the  safest 
and  most  efficient  treatment  in  this  stage.  When  the  disease  has 
become  chronic,  the  uterine  cavity  should  be  washed  with  hot  bichlo- 
ride solution  1  to  10,000,  passed  in  through  a  two-way  uterine  irri- 
gator. Large  quantities  of  this  fluid  should  be  employed,  one  or  two 
quarts  at  a  time,  and  the  treatment  should  be  repeated  every  second 
day.  If  the  disease  still  lingers  in  spite  of  this  treatment,  the  cer 
vix  should  be  dilated,  and  the  uterus  thoroughly  curetted,  swabbed 
with  a  ten  per  cent,  solution  of  zinc  chloride,  and  packed  with 
iodoform  gauze.  When  the  disease  has  extended  to  the  parame- 
trium, tubes,  ovaries,  and  pelvic  peritoneum,  causing  the  local  and 
general  symptoms  of  acute  pelvic  peritonitis,  free  movements  of  the 
bowels,  prolonged  hot  baths,  and  hot  vaginal  douches  are  indicated 
until  the  acute  stage  has  passed  and  very  definite  localizing  symp- 
toms point  to  the  use  of  the  knife. 

VAGINITIS. 

Inflammation  of  the  vagina,  at  one  time  regarded  as  the  most  char- 
acteristic manifestation  of  gonorrhcea  in  the  female  is  Jiow  recognized 

12 


178  GENITO-UEINAKT  DISEASES  AND   SYPHILIS. 

as  occurring  much  less  frequently  than  urethritis  or  endometritis. 
The  many  layers  of  squamous  epithehum  are  usually  sufficient  to 
prevent  penetration  of  the  gonococci.  When,  however,  the  vaginal 
mucous  membrane  is  succulent  and  the  spaces  between  the  epithelial 
cells  are  widened,  as  in  infants  and  children,  or  in  young  virgins,  the 
gonococci  may  penetrate  deeply  and  produce  a  true  vaginitis.  The 
vaginal  inflammation  sometimes  noted  in  older  women  is  often  due 
to  the  irritating  effect  of  decomposing  discharges  which  flow  from  the 
endometrium. 

Symptoms.— A  sense  of  weight  and  burnir^g  in  the  vagina,  aggra- 
vated by  motion,  a  free  purulent  discharge,  and  slight  fever  and  malaise 
are  the  only  symptoms  of  which  the  patient  complains.  An  examina- 
tion shows  the  vaginal  mucous  membrane  reddened,  oedematous,  and 
freely  suppurating,  and  its  walls  somewhat  stiffened  by  recent  inflam- 
matory exudation.  The  epithelium  is  eroded  in  places,  and  there  are 
observed  extensive  granular  patches,  especially  in  pregnant  women. 
Often  there  is  so  much  tenderness  that  examination  either  by  the 
finger  or  by  the  speculum  is  impossible. 

Diagnosis, — This  is  founded  on  ocular  and  digital  examination 
showing  an  acute  inflammation  of  the  vagina,  usually  associated  with 
urethritis  and  vulvitis,  and  often  with  endometritis.  The  gonococcus 
may  be  found. 

Prognosis. — In  itself  gonorrhoeal  vaginitis  is  not  a  serious  affection. 
It  is  usually  cured  in  two  or  three  weeks.  Exceptionally  it  becomes 
chronic,  and  in  prostitutes  causes  a  stiffened,  dry,  rough  condition  of 
the  mucous  membrane,  termed  xerosis  vaginae. 

Treatment. — This  should  be  cleansing  and  antiseptic.  Twice  a  day 
the  vagina  is  flushed  out  with  two  quarts  of  normal  saline  solution 
(seven-tenths  per  cent.)  containing  1  to  4000  corrosive  sublimate. 
This  douche  is  best  given  from  a  fountain  syringe  raised  two  to  four 
feet.  During  its  administration  the  patient  should  lie  on  her  back, 
with  the  hips  slightly  elevated,  or,  better  still,  should  assume  the  knee- 
elbow  position.  When  there  is  a  bath-tub  these  flushings  are  easily 
managed. 

After  each  washing  the  vagina  is  packed  with  a  cotton-wool  tam- 
pon dipped  in  hydrastis-glycerin  mixture  1  to  10,  or  with  iodoform 
gauze,  thus  keeping  its  walls  from  coming  in  contact  and  acting  as 
mutual  poultices ;  the  packing  also,  by  its  astringent  action,  rapidly 
reduces  the  discharge. 

When  the  acute  symptoms  have  subsided,  a  speculum  is  intro- 
duced, and  the  inflamed  and  granular  patches,  or  the  entire  vagina  if 
all  its  surfa-ce  is  involved,  are  painted  with  ten  per  cent,  silver  nitrate 


GONOKRHGEA    IN    WOMEN.  179 

solution.  This  is  repeated  in  three  days  if  necessary.  Tincture 
of  iodine  may  be  used  in  place  of  the  silver  nitrate.  In  cases  seen 
early,  or  where  the  inflammation  is  not  so  acute  that  insertion  of  a 
speculum  is  very  painful,  the  silver  nitrate  painting  is  indicated  from 
the  first. 

In  chronic  cases,  irrigation,  followed  by  paintings  of  the  vagina 
with  strong  solutions  of  silver  or  copper  ten  per  cent,,  or  iodine  pure, 
and  then  by  tamponing  with  iodoform  gauze,  is  repeated  daily  for  from 
five  to  seven  days ;  then  dilute  antiseptic  washes  are  employed  once 
daily  for  two  weeks  till  epithelial  regeneration  is  completed.  Sup- 
positories of  tannin  and  boric  acid  (ten  grains  of  each)  inserted  twice 
daily  will  greatly  lessen  the  discharge,  and  will  sometimes  cure  a 
chronic  inflammation  when  other  means  have  failed. 

GONORRH(EA   IN   CHILDREN. 

Male  Children. — The  course  of  gonorrhoea  as  observed  in  male 
children  is  not  markedly  different,  in  symptomatology,  duration,  or 
treatment,  from  the  disease  as  it  occurs  in  adults.  It  is  a  rare  dis- 
ease, at  least  in  boys  under  twelve  years  of  age,  in  this  respect 
affording  a  marked  contrast  to  gonorrhoea]  vulvo-vaginitis  observed 
in  the  opposite  sex.  The  cause  is  usually  an  attempt  at  intercourse, 
often  suggested  by  a  much  older  female.  Very  exceptionally  the 
contagion  may  be  mediate  by  means  of  fabrics  or  by  foreign  bodies 
previously  infected  being  introduced  within  the  urethra.  When  the 
disease  develops  in  boys  over  twelve  years  of  age  it  is  usually  acquired 
in  the  ordinary  manner. 

Symptoms. — These  are  the  same  as  have  been  already  described. 
They  develop  more  quickly  after  exposure  to  contagion,  and  run  a 
somewhat  more  acute  course  than  is  customary  in  the  adult,  the  whole 
penis  usually  being  swollen,  the  discharge  being  profuse,  and  the  child 
complaining  bitterly  of  the  pain  incident  to  micturition  and  erection. 

Complications. — Of  these  the  most  frequent  is  balanoposthitis, 
incident,  no  doubt,  to  the  phimosis  usually  present  in  children  and  to 
the  vulnerability  of  the  mucous  coverings  of  the  glans  and  foreskin. 
Indeed,  other  complications  are  rare,  though  a  number  of  well-authen- 
ticated instances  of  epididymitis  are  reported.  Hyperacute  posterior 
urethritis  and  urethro-cystitis  are  by  no  means  exceptional.  There  is 
usually  pronounced  fever. 

Diagnosis. — This  is  founded  on  the  presence  of  the  gonococcus. 
Since  it  has  been  shown  that  in  the  normal  urethra  there  are  micro- 
organisms identical  in  all  respects  with  the  gonococcus,  identification 
of  these  micro-organisms  under  the  microscope  is  not  a  proof  of  the 


180  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

specific  nature  of  the  affection  in  medico-legal  cases,  though  for  clin- 
ical purposes  it  can  be  considered  sufficient.  When,  as  often  occurs., 
there  is  a  probability  of  cases  coming  to  court,  the  specific  nature 
of  the  affection  should  be  proved  by  cultivation  of  the  gonococcus 
on  artificial  blood  serum.  The  growth  is  said  to  be  absolutely  char- 
acteristic and  to  differentiate  satisfactorily  this  micro-organism  from 
all  others. 

The  search  for  the  gonococcus  should  always  be  made,  since 
simple  irritative  urethritis  is  by  no  means  uncommon  in  children, 
and  is  in  the  beginning  of  its  course  not  to  be  distinguished  clini- 
cally from  true  gonorrhoea.  This  simple  urethritis  is  often  excited 
by  the  introduction  of  foreign  bodies,  by  a  simple  balanoposthitis, 
and  by  the  irritation  incident  to  the  passage  of  highly  condensed 
urine. 

It  is  usually  mild  and  of  short  duration,  contrasting  with  the  in- 
flammation resulting  from  the  presence  of  the  gonococcus. 

The  prognosis  is  favorable,  the  discharge  usually  ceasing  in  from 
three  to  six  weeks.  In  weak,  strumous,  cachectic  children  it  is  liable 
to  last  much  longer  and  may  run  into  gleet.  Stricture  has  been 
observed  as  a  sequel. 

Treatment. — This  consists  in  rest  in  bed,  the  relief  of  phimosis  by 
operation,  circumcision  being  performed  if  the  parts  are  not  too  greatly 
swollen,  light  diet,  hot  baths,  the  administration  of  laxatives  when 
required,  and  medicines  calculated  to  subdue  the  fever,  render  the 
urine  bland  and  slightly  antiseptic,  and  control  the  painful  erections. 
These  indications  should  be  met  by  aconite  in  small  doses,  boric  acid, 
and  potassium  bromide.  An  excellent  formula  for  a  child  of  five 
years  is  the  following : 

R   Potassii  bromidi,  ^ii ; 
Acidi  horici,  gr.  xlviii ; 
Tinct.  aconiti,  gtt.  vi ; 
Tinct.  belladonnse,  gtt.  xxiv ; 
Spts.  setheris  nit.,  f^iii ; 
Mist,  potassii  citratis,  q.  s.  ad  f^vi. 
M.     S. — Dessertspoonful  in  water  every  two  hours. 

The  penis  should  be  kept  wrapped  in  cloths  wet  in  lead  water  and 
dilute  alcohol. 

On  the  subsidence  of  the  acute  inflammatory  symptoms  injections 
may  be  administered.  These  should  contain  the  remedies  used  in 
similar  conditions  of  the  adult,  but  should  be  somewhat  weaker, 
varying  from  one-half  to  two-thirds  strength,  according  to  the  age  of 


GONOKRHCEA   IN   WOMEN.  Igl 

the  child.     They  should  never  be  used  strong  enough  to  cause  acute 
or  prolonged  pain.     It  is  well  to  begin  with  the  following  injection : 

R   Ext.  opii  aq.,  gr.  vi ; 

Acidi  carbolici,  gtt.  xv  ; 

Liq.  plumbi  subacetat.  dil.,  f^vi. 
M.     S.— Use  locally. 

Later  an  antiseptic  and  astringent  injection,  as  the  following, 
should  be  employed : 

R  Hydrarg.  chlorid.  corros.,  gr.  -^j^; 

Acidi  borici,  ^i  ; 

Zinci  sulpho-carbolat.,  gr.  xii ; 

Liq.  hydrogen,  peroxid.,  f^ss  ; 

Aquae  rosse,  fjvss. 
M.     S.— Use  locally. 

These  injections  should  be  administered  immediately  after  the 
child  urinates,  from  half  a  drachm  to  a  drachm  being  thrown  in  each 
time.  As  soon  as  the  fever  subsides  the  internal  administration  of 
salol  is  serviceable.  This  may  be  given  in  doses  of  one  to  three 
grains  six  times  a  day,  depending  upon  the  age  of  the  patient,  and 
may  be  combined  with  balsam  of  copaiba  or  oil  of  sandal  wood  in 
appropriate  doses.  When  the  fever  persists  and  assumes  an  irregular 
intermittent  type  full  doses  of  quinine  night  and  morning  will  be  found 
serviceable. 

Female  Children. — In  female  children  gonorrhoea  takes  the 
form  of  urethro-vulvo-vaginitis.  It  is  different  from  the  disease  as  it 
appears  in  the  adult,  since  in  the  latter  the  vagina  is  only  exception- 
ally involved. 

There  are  two  distinct  forms:  1,  catarrhal  or  irritative;  2,  gonor- 
rhoeal. 

Catarrhal  vulvo-vaginitis  may  be  caused  by  any  irritant,  such  as 
prolonged  contact  of  irritating  urine  or  of  faeces,  lack  of  cleanliness, 
seat-worms,  decomposing  discharges  incident  to  exanthemata,  etc. 
The  inflammation  is  usually  confined  to  the  vulva,  the  vagina  being 
but  slightly  involved,  and  the  urethra  escaping  entirely. 

The  symptoms  are  those  of  ordinary  inflammation,  as  heat,  redness, 
swelling,  pain,  or  itching,  increased  by  contact  with  urine.  There  are 
often  extensive  excoriations,  or  even  distinct  ulcers. 

The  diagnosis  is  founded  on  the  absence  of  gonococci  and  on  the 
presence  of  vast  numbers  and  varieties  of  other  micro-organisms, 
the  comparatively  mild  course  of  the  affection,  though  it  may  be 
extremely  chronic  and  rebellious  to  treatment,  and  the  absence  of 
involvement  of  the  urethra  and  vagina.     The  prognosis  is  good. 


182  GENITO-UKINAKY  DISEASES   AND  SYPHILIS. 

The  treatment  consists  in  removal  of  the  cause  and  in  strict  local 
cleanliness.  Since  this  affection  is  very  commonly  associated  with 
seat-worms,  these  should  always  be  searched  for.  Mild  antiseptic 
washes,  as  boric  acid,  followed  by  dusting  poAvders,  such  as  finely 
powdered  bismuth  or  zinc  oxide,  and  the  application  of  a  thin  layer 
of  cotton  between  abraded  and  inflamed  surfaces, — i.e.,  between 
the  greater  and  the  lesser  lip  of  each  side, — usually  result  in  cure. 
When  the  disease  becomes  chronic,  stronger  astringent  injections  and 
washes  are  required. 

GoNORRH(EAL  VuLvo  -  VAGINITIS . — This  is  an  affection  which  recent 
studies  have  shown  to  be  much  more  prevalent  and  serious  in  its  ulti- 
mate effects  than  has  generally  been  believed. 

Cause. — In  the  new-born  and  in  young  infants  gonorrhoeal  vulvo- 
vaginitis is  acquired  from  the  mother,  either  from  direct  contagion 
during  parturition,  or  from  mediate  contagion  later  through  the 
agency  of  towels,  wash-rags,  fingers,  etc.  When  it  develops  after  the 
nursing  period  it  is  usually  due  to  mediate  contagion.  Thus,  it  has 
been  shown  that  when  one  case  is  introduced  into  an  institution  the 
disease  spreads  rapidly,  probably  by  the  medium  of  the  bath  or 
towels.  The  genital  mucous  membrane  of  the  child  seems  to  be  ex- 
ceedingly sensitive  to  the  gonococcus.  Exceptionally  vulvo-vaginitis 
is  caused  by  criminal  practices.  When  these  are  suspected,  and  con- 
sequently when  there  is  a  possibility  of  a  medico-legal  contest,  the 
presence  of  the  gonococcus  should  always  be  confirmed  by  culture  on 
artificial  media. 

Symptoms. — These  are  pronounced.  The  discharge  is  free,  puru- 
lent, often  blood-stained.  It  comes  from  the  urethra,  vagina,  and 
vulva.  There  are  great  swelling,  intense  hypersemia  of  the  mucous 
surfaces,  which  bleed  readily  when  touched,  pronounced  ardor 
urinse,  and  marked  and  persistent  fever.  There  is  often  bitter  com- 
plaint of  severe  abdominal  and  pelvic  pain.  On  rectal  examination 
the  womb  may  be  found  tender  and  swollen. 

The  diagnosis  is  founded  on  the  presence  of  gonococci,  the  involve- 
ment of  the  urethra,  and  the  severity  of  the  symptoms. 

T\\Q  prognosis  is  good.  None  the  less  cases  of  peritonitis  and  death 
have  been  reported,  and  on  the  basis  of  apparently  clear  clinical  records 
it  has  been  shown  that  this  inflammation  in  infancy  may  occasion  im- 
perfect development  of  the  genitalia,  sterility,  and  chronic  invalidism  in 
later  life.     The  local  conditions  are  apt  to  be  rebellious  to  treatment. 

Treatment. — Special  care  must  be  taken  to  guard  against  transfer- 
ence of  the  inflammation  to  the  eye.  This  is  peculiarly  liable  to 
happen  iii  public  institutions.     The  child  should  be  put  to  bed,  and 


GONOKKHCEA   IN   WOMEN. 


183 


given  a  milk  diet,  the  bowels  should  be  opened  regularly,  and  a  hot 
bath  administered  night  and  morning.  Three  times  daily  a  small 
soft  rubber  catheter  should  be  introduced  into  the  vagina,  and  there 
should  be  gently  injected  first  four  ounces  of  a  one  per  cent,  hot 
solution  of  sodium  bicarbonate,  then  the  same  quantity  of  a  weak  hot 
antiseptic,  such  as  bichloride  of  mercury  1  to  20,000,  carbolic  acid 
1  to  200,  boric  and  salicylic  acids  ten  grains  of  the  former  and  five 
grains  of  the  latter  to  the  ounce,  or  protargol  1  to  5000.  After  this 
irrigation  the  vulva  should  be  dried  carefully  with  moist  absorbent 
cotton,  and  dusted  with  a  powder  made  of  boric  acid,  zinc  oxide,  and 
talc  equal  parts,  and  between  the  labia  should  be  inserted  a  thin  layer 
of  absorbent  cotton. 

If  these  injections  cause  pain  they  must  be  weakened  until  they  are 
borne  well.  As  the  acute  stage  passes  they  are  gradually  strength- 
ened, hydrastis  being  added.  For  the  accompanying  urethritis  small 
doses  of  salol  and  boric  acid  are  indicated,  or  the  prescriptions  given 
on  page  135  can  be  advantageously  used. 

The  general  health  should  receive  careful  attention,  and  in  stru- 
mous or  cachectic  patients  treatment  may  have  to  be  prolonged  for 
weeks  or  months  before  cure  is  effected. 


CHAPTER  V. 

COMPLICATIONS    OF    GONORRH(EA. 

In  the  large  majority  of  patients  suffering  from  urethritis,  when 
treatment  has  been  judiciously  instituted  from  the  beginning  of  the 
attack  there  are  no  complications  ;  that  is,  the  disease  is  limited  to 
the  urethra  and  remains  superficial.  Exceptionally  the  inflammation 
exhibits  a  tendency  to  extend  wide  of  the  urethra  or  even  to  attack 
other  parts  of  the  body.  In  these  cases  there  is  usually  mixed 
infection,  the  ordinary  pus  microbes  being  present  and  producing 
either  local  inflammations  or  a  mild  or  even  severe  form  of  septic 
poisoning,  though  there  is  evidence  that  the  gonococcus  in  itself  or 
the  ptomaines  engendered  by  it  may  produce  many  of  the  compli- 
cations which  are  encountered  in  these  inflammations. 

There  seems  to  be  a  personal  susceptibility  towards  the  develop- 
ment of  such  complications,  since  certain  patients  never  have  the 
good  fortune  to  run  through  a  simple  uncomplicated  attack. 

As  to  the  cause  of  complications,  in  general  terms  it  is  true  that  all 
factors  which  tend  to  exacerbate  an  attack  of  gonorrhoea  predispose  to 
complications. 

The  fact  that  these  complications  are  usually  due  to  mixed  infec- 
tion is  one  which  should  be  borne  in  mind  as  indicating  the  necessity 
for  perfect  cleanliness  in  all  local  manipulations. 

The  complications  most  frequently  encountered  in  the  male  are  ; 
1.  Balanitis  and  balanoposthitis.  2.  Phimosis  and  paraphimosis. 
3.  Lymphangitis  and  lymphadenitis.  4.  Folliculitis  and  periurethral 
abscess.  5.  Cowperitis.  6.  Prostatitis.  7.  Vesiculitis.  8.  Epididy- 
mitis. 

The  complications  common  to  both  the  male  and  the  female  are : 
1.  Cystitis.  2.  Ureteritis  and  uretero-pyelitis.  3.  GonorrhcBal  conjunc- 
tivitis. 4.  Gonorrhceal  rheumatism,  including  such  manifestations  as 
arthritis,  endocarditis,  and  meningitis. 

In  men  the  most  frequent  complication  is  epididymitis. 

Balanitis  and  Balanoposthitis. — Though  gonococci  seem  to 
play  no  causative  rdle  in  the  production  of  balanitis,  or  inflammation 
of  the  surface  of  the  glans  penis,  this  is  a  frequent  complication  of 
gonorrhoea. 

184 


COMPLICATIONS   OF    GONOREHCEA. 


185 


The  symptoms,  diagnosis,  and  treatment  have  already  been  de- 
scribed, the  gonorrhoea!  form  of  the  affection  running  a  course  which 
does  not  differ  from  that  due  to  other  causes.     (See  page  31.) 

Phimosis,  inflammatory  in  character  and  secondary  to  balano- 
posthitis,  has  already  been  described  (see  page  8).  This  is  always 
a  troublesome  condition,  since  it  materially  interferes  with  treat- 
ment and  may  render  the  diagnosis  exceedingly  difficult.  Swelling 
may  become  so  great  that  a  certain  amount  of  sloughing  occurs. 
The   inflammatory   induration  usually  entirely    disappears.      It  may 

Fig.  65. 


(xonorrhueul  phimosis. 

remain,  leaving  a  thickened  prepuce,  which  is  readily  fissured  and 
eroded. 

If  the  patient  first  comes  under  treatment  with  a  vague  history 
and  with  an  oedematous  swollen  prepuce  from  the  orifice  of  which 
blood  and  pus  flow,  it  is  sometimes  difficult  to  determine  correctly  the 
source  and  nature  of  the  discharge. 

Whether  or  not  all  the  discharge  comes  from  the  preputial  sac  or 
a  part  of  it  from  the  urethra  can  be  ascertained  in  this  way.  The 
preputial  sac  is  thoroughly  washed  out  by  means  of  a  syringe  to  which 
is  attached  a  soft  rubber  catheter  small  enough  to  pass  within  the 
preputial  orifice,  and  immediately  after  this  washing  the  patient  is 


186  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

directed  to  urinate.     If  tlie  urine  contains  much  pus,  the  latter  must 
come  from  the  urethra. 

Chancroidal  balanitis  can  be  suspected  only  from  the  development 
of  bubo,  the  rapid  and  progressive  swelling,  and  the  free  discharge, 
and  from  auto-inoculation,  other  sores  forming  on  the  free  border  of 
the  preputial  opening,  or  on  the  scrotum  or  other  portions  of  the 
body  with  which  the  discharge  comes  in  contact.  The  main  points 
of  difference  between  gonorrhoeal  and  chancroidal  phimosis  may  be 
summed  up  as  follows  : 

Phimosis  f?'om  Gonorrhoea.  Phimosis  with  Preputial  Chancroid. 

No  history  of  sore  on  glans  or  prepuce.      History  of  sore.     Swelling  often  due  to 

Swelling  in  foreskin  at  first   almost         presence    of   plastic    lymph    around 

entirely  (Edematous.  ulcer. 

Discharge  usually  purulent,  and  contains      Discharge  often  sanguinolent ;  no  gono- 

gonococci.  cocci. 

No  definite  area  harder  or  more  tender      Distinct  spot   usually   discoverable   by 

than  the  rest.  palpation. 

Chordee  often  present.  Never  any  true  chordee. 

Ardor  urinse  extends  along  whole  length      Ardor  urinsB  only  when  the  urine  comes 

of  canal.  in  contact  with  the  inflamed  or  ulcer- 

ated foreskin. 
Vesical  symptoms  not  infrequent.  No  vesical  symptoms  in  uncomplicated 

cases. 
Bubo  rare.  Bubo  common. 

Phimosis  and  balanitis  from  chancre  may  be  diagnosed  by  the 
typical  induration  of  the  primary  sore  and  by  the  characteristic 
lymphatic  involvement  and  subsequent  development  of  secondary 
symptoms. 

Phimosis  and  balanitis  due  to  secondary  or  tertiary  manifesta- 
tions of  syphihs  may  occur.  The  diagnosis  will  in  the  first  case 
depend  upon  the  existence  of  typical  eruptions  in  other  parts  of  the 
body.  The  tertiary  manifestations  may  be  suspected  from  the  history 
of  the  case.  The  mode  of  onset  is  usually  characteristic  of  syphihs, 
a  lesion  appearing  in  the  form  of  an  infiltration  or  a  hard  node  and 
preceding  the  development  of  phimosis. 

The  symptomatology  and  treatment  of  inflammatory  phimosis 
have  already  been  discussed. 

Paraphimosis. — This,  as  is  the  case  with  phimosis,  is  dependent 
upon  inflammatory  swelling  of  the  foreskin,  which,  after  rolling  back 
or  being  forced  back,  can  no  longer  be  brought  forward.  The  ques- 
tion of  differential  diagnosis  is  scarcely  raised  here,  since  the  urethral 
meatus  is  freely  exposed  and  the  discharge  can  be  seen  escaping 
through  it.     The  treatment  has  been  described.     (See  page  18.) 


COMPLICATIONS   OF    GONOKRHCEA.  187 

Lymphangitis.  — In  a  small  percentage  of  gonorrhoeal  cases  a 
simple  lymphangitis  or  inflammation  of  the  lymphatic  vessels  occurs 
as  a  result  of  local  infection. 

This  is  often  caused  by  neglect  of  cleanliness,  the  discharge  being 
retained  within  the  fossa  navicularis  either  by  a  congenitally  narrow 
meatus  or  by  a  faulty  method  of  dressing.     (See  page  28.) 

Lymphadenitis  or  Bubo. — Adenitis  of  the  glands  of  the  groin, 
or  bubo,  is  a  comparatively  rare  complication  of  gonorrhoea.  It  occurs 
chiefly  during  the  second  stage  of  the  disease. 

It  is  commonly  excited  by  excesses,  exposure,  or  violent  and 
long-continued  exertion.  Persons  who  are  much  on  their  feet  suffer 
more  frequently  from  this  complication  than  those  whose  occupation 
allows  of  more  rest.  The  gland  usually  affected  is  one  of  the  super- 
ficial set  lying  just  below  Poupart's  ligament,  embedded  in  the  sub- 
cutaneous cellular  tissue  and  placed  above  the  fascia  lata. 

Symptoms. — A  small,  painful  tumor  makes  its  appearance  in  the 
groin;  it  is  tender  on  pressure,  and  the  pain  is  aggravated  by  stand- 
ing or  walking.  It  is  at  first  freely  movable  beneath  the  skin,  but 
afterwards  contracts  adhesions  to  the  latter  and  to  the  surrounding 
parts,  and  becomes  doughy  in  feel  and  reddened  or  purplish  in  hue. 
The  majority  of  these  cases  after  reaching  this  condition  will  sub- 
side under  appropriate  treatment,  disappearing  in  time.  In  some 
instances,  however,  particularly  in  patients  of  scrofulous  tendencies 
or  in  those  whose  vitality  is  lessened  through  bad  habits  or  overwork, 
suppuration  ensues,  ushered  in  by  the  local  and  general  phenomena 
of  abscess-formation.  The  discharge  from  a  suppurative  gonorrhceal 
bubo  does  not  contain  gonococci. 

Treatment. — Gonorrhoeal  bubo  can  often  be  relieved  without  sup- 
puration by  prolonged  hot  baths,  followed  by  rest  in  bed,  the  applica- 
tion of  the  iodine,  mercury,  and  belladonna  ointment  over  the  inflamed 
region  and  the  use  of  a  bag  of  hot  shot  containing  two  to  four  pounds 
placed  directly  over  the  inflamed  part. 

If  suppuration  takes  place,  the  treatment  should  be  that  directed  in 
the  case  of  chancroidal  bubo, — i.e.,  puncture  under  antiseptic  precau- 
tions and  evacuations  of  the  contents  of  the  abscess,  followed  by  anti- 
septic flushings  of  the  sac  and  the  application  of  a  sterile  dressing  held 
in  place  by  a  pressure  bandage.  This  puncture,  evacuation,  and  wash- 
ing out  may  be  repeated  twice.  If  the  cavity  again  fill  up,  free  incision, 
curetting,  and  packing  with  iodoform  gauze  are  indicated.  (See  p.  57.) 

Complete  removal  of  gonorrhceal  buboes  before  they  have  broken 
down  is  justifiable,  provided  they  become  progressively  worse  in 
spite  of  one  or  two  days'  careful  treatment. 


188  GEXITO-UEIXARY   DISEASES   AND    SYPHILIfe. 

Follicular  and  Periurethral  Abscess. — Gonorrhceal  inflamma-  • 
tion.not  only  spreads  along  the  surface  of  the  urethra,  but,  dipping  into 
the  mucous  follicles  and  gland  ducts,  involves  their  entire  mucous  sur- 
face. Often  if  the  finger  is  passed  along  the  under  surface  of  the  ure- 
thra there  can  be  felt  distinct  nodulations,  due  to  the  follicular  swelling. 
At  the  meatus,  where  the  glands  and  follicles  are  especially  well  devel- 
oped, pus  may  be  seen  to  escape  from  their  orifices  on  pressure. 

If  the  ducts  become  closed  from  swelKng  or  from  inflammatory 
exudation,  the  catarrhal  secretion  of  the  follicles  being  no  longer  able 
to  escape  into  the  urethra,  small  pockets  of  pus,  or  fohicular  abscesses,, 
appear.  These  follicular  abscesses  are  most  frequently  located  in  the- 
first  inch  of  the  urethra,  the  follicles  being  numerous  in  this  region. 
They  appear  as  small,  round,  tender  nodules,  which  may  open  inter- 
nally without  involving  the  skin,  the  duct  finally  becoming  patulous. 
Frequently,  however,  the  skin  reddens  and  is  no  longer  movable  over 
the  nodule,  and  the  latter  discharges  its  contents  externally.  In  this 
case  the  urethral  opening  of  the  gland  usually  remains  closed,  and 
no  fistula  results,  even  though  the  frsenum  be  completely  undermined 
by  suppurating  follicles  on  each  side.  The  frsenum  itself  is  apt  to  be 
markedly  oedematous  during  the  period  of  pus-formation  in  the  fol- 
licles lying  near  its  point  of  attachment  behind  and  below  the  meatus. 
On  stripping  back  the  foreskin  the  projecting  swelling  is  readily  seen 
entirely  obliterating  the  normal  depression  situated  at  the  side  of  the 
freenal  attachment.  When  external  rupture  and  discharge  of  pus  take 
place,  there  is  often  left  a  troublesome  sinus. 

Sometimes  the  lacuna  magna  remains  in  an  inflammatory  condi- 
tion long  after  the  urethral  mucous  membrane  has  returned  to  a 
healthy  state.  The  opening  of  this  foUicle  is  so  large  that  it  is  not 
readily  obliterated,  yet  it  may  be  narrowed  to  such  an  extent  that 
healing  injections  do  not  penetrate  to  its  deeper  portions.  Such  an 
inflammation  will  occasion  a  long-continued  discharge. 

At  the  frsenum  the  mucous  follicles  are  surrounded  by  fibrous^ 
tissue :  hence  this  hmits  abscess-formation.  Farther  back  along  th(^ 
urethra  this  investment  of  connective  tissue  is  less  marked :  hence 
the  inflammation  may  readily  extend  into  the  cavernous  tissue,  and 
in  case  the  inflammation  goes  on  to  suppuration,  periurethral  abscess- 
will  be  formed. 

Periurethral  abscess  begins  as  a  case  of  folliculitis  or  adenitis,  but 
the  swelling  rapidly  increases,  and  is  attended  with  pain,  tenderness,, 
and  often  some  diminution  in  the  size  of  the  stream  passed  during 
urination.  The  swelhng  may  suddenly  subside  from  opening  of  the 
obstructed  duct.     This  probably  wall  be  denoted  by  diminution  in  the 


COMPLICATIONS   OF    GONOREHCEA.  189 

":size  and  tension  of  the  tumor,  by  blood  and  pus  in  the  urine,  and  by 
a  sense  of  relief  from  pain.  The  subsidence  may  inaugurate  a  speedy 
cure,  or,  if  the  urine  enters  the  abscess-cavity,  may  be  shortly  followed 
by  urinary  extravasation.  Commonly  the  skin  becomes  reddened  and 
inflamed,  and  the  pus  is  evacuated  externally,  after  which  the  abscess- 
cavity  heals. 

If  the  abscess  opens  externally  and  internally  at  the  same  time,  a 
urinary  fistula  results,  and  one  difficult  to  cure. 

Periurethral  abscesses  occur  at  any  portion  of  the  anterior  urethra, 
but  are  most  frequently  observed  in  the  region  of  the  bulb.  They 
may  be  attended  with  considerable  inflammatory  induration  of  the 
•corpus  spongiosum,  which  may  ultimately  undergo  complete  resolu- 
tion, or  may  remain  permar^ently,  constituting  an  incurable  chordee 
and  preventing  intercourse. 

When  urinary  extravasation  occurs  it  is  attended  by  rapid  increase 
in  pain  and  swelling,  and  infiltration  of  sometimes  the  greater  portion 
of  the  corpus  spongiosum.  The  local  pain  is  much  increased  during 
each  urination.  There  is  commonly  an  opening  formed  externally, 
which  allows  of  free  purulent  discharge  and  results  in  urinary  fistula. 
•Sometimes  an  extensive  sloughing  process  is  inaugurated,  attended 
with  well-marked  general  septic  symptoms.  Even  in  the  mildest  case 
of  urinary  extravasation  there  may  be  sufficient  destruction  of  the 
■erectile  tissue  of  the  spongy  body  to  cause  great  deformity  of  the  penis 
Avhen  the  organ  is  erect. 

Treatment. — Gentle  pressure  and  massage  are  sometimes  successful 
in  rendering  patulous  the  obstructed  duct  of  an  inflamed  gland  or 
follicle.  When  the  swelling  becomes  marked  and  painful,  cloths  wet 
with  alcohol  and  dilute  lead  water  should  be  kept  about  the  penis. 
When  the  skin  becomes  adherent  and  softening  occurs,  the  folhcles 
should  be  opened,  curetted,  and  packed  with  iodoform  gauze.  They 
usually  heal  kindly  from  the  bottom.  When  they  have  ruptured  spon- 
taneously, causing  a  troublesome  sinus,  this  should  be  converted  into 
an  open  wound,  and  be  curetted  and  packed.  When  there  are  both 
an  internal  and  an  external  opening,  the  formation  of  a  permanent 
fistula  is  guarded  against  by  permanent  or  intermittent  catheteriza- 
tion, no  urine  being  allowed  to  escape  through  the  artificial  opening. 
Fistulae  at  times  heal  spontaneously.  If  not,  a  plastic  operation  is 
indicated. 

When  the  lacuna  magna  becomes  involved  in  a  chronic  inflam- 
mation, which,  though  not  going  on  to  abscess-formation,  persists 
and  keeps  up  discharge,  a  fine  grooved  director  should  be  passed  to 
,  its  deepest  part,  and  it  should  be  slit  out  into  the  urethra. 


190  GENITO-UKINAEY   DISP:ASES   AND   SYPHILIS. 

Periurethral  abscess  when  once  formed  demands  immediate  evac- 
uation, and  this  indication  is  even  more  imperative  when  there  is 
urinary  extravasation.  The  formation  of  a  fistula  is  guarded  against 
by  permanent  catheterization. 

Prostatitis. — After  the  gonorrhoeal  inflammation  has  reached  its 
full  development  in  the  prostatic  urethra — that  is,  during  the  third 
week  of  the  attack  or  subsequent  to  this  time — it  may  extend  into  the 
substance  of  the  prostate  gland.  The  involvement  of  the  prostate 
occurs  in  but  a  small  percentage  of  cases,  and  is  at  times  observed 
when  the  posterior  urethritis  is  so  slight  as  to  have  given  rise  to  no 
marked  symptoms.  The  follicles  and  glandular  elements  of  this  body 
are  chiefly  involved,  the  muscular  tissue,  forming  the  greater  portion 
of  its  mass,  remaining  unaffected,  except  in  the  most  severe  cases. 

Simple  acute  prostatitis  represents  the  mildest  form  of  acute  pros- 
tatitis. It  is  probably  present  to  a  minor  degree  in  every  case  of 
acute  posterior  urethritis,  and  represents  little  more  than  inflamma- 
tory hyperemia. 

Acute  follicular  prostatitis  is  usually  due  to  some  cause  exciting 
renewed  intensity  of  gonorrhoeal  inflammation,  such  as  excessive 
drinking  or  coitus. 

The  patient  complains  of  burning  during  urination,  and  sharp, 
shooting,  clearly  localized  pains  during  the  passage  of  the  last  drops. 
These  pains  are  located  in  the  deep  urethra.  On  rectal  examination 
the  prostate  is  found  to  be  not  materially  enlarged,  but  presents  one 
or  two  well-defined  nodules,  usually  in  one  lobe  only.  These  are 
intensely  indurated,  contrasting  markedly  with  the  soft  condition  of 
the  remainder  of  the  gland,  and  are  painful  on  pressure.  The  inflam- 
mation is  confined  to  the  follicles  and  the  perifollicular  tissues. 

Parenchymatous  prostatitis,  after  it  runs  on  to  suppuration,  is  the 
most  serious  form  of  the  afl'ection.  The  whole  structure  of  the  gland 
is  involved.  There  is  not  only  great  inflammatory  hypersemia,  but 
also  marked  exudation.     The  constitutional  reaction  is  pronounced. 

The  abscess  usually  ruptures  into  the  urethra.  This  will  be  de- 
noted by  aggravation  of  the  pain  during  the  act  of  defecation  or  of 
micturition,  followed  by  a  free  discharge  of  blood  and  pus  through  the 
urethra,  and  the  immediate  amelioration  of  all  the  symptoms.  This 
is  considered  the  most  immediately  favorable,  and  is  the  common 
termination ;  it  may  be  followed  by  urinary  extravasation,  requiring 
operation,  but  this  is  unusual. 

The  pus  may  penetrate  the  capsule  of  the  gland  at  any  point.  If 
it  is  not  evacuated  into  the  urethra,  it  is  prone  to  rupture  into  the 
rectum.     If  it  does  not  open  into  either  the  rectum  or  the  urethra,  it 


COMPLICATIONS   OF    GONORRHOEA.  191 

generally  burrows  into  the  perineum  or  the  ischio-rectal  fossa.  It  may 
burrow  in  almost  any  direction,  cases  being  recorded  in  which  it 
opened  through  the  sciatic  foramen,  at  the  edge  of  the  false  ribs,  and 
into  the  abdominal  cavity. 

At  times  prostatic  abscesses  develop  in  so  quiet  a  manner  as  to 
escape  observation.  There  are  no  symptoms  other  than  those  com- 
monly noted  in  the  congestive  form  of  the  disease  ;  these  are  so  slight 
that  the  patient  makes  no  complaint.  After  some  days  the  symp- 
toms of  septic  absorption,  characterized  by  rigors  and  fever,  set  in ; 
and  examination  by  the  rectum  shows  a  large  fluctuating  swelling 
or  prostatic  abscess.  Hence  in  all  cases  of  urethritis  attended  by 
undue  systemic  disturbance,  examination  should  be  made  to  discover 
whether  or  not  this  insidious  form  of  prostatic  trouble  is  developing. 
(For  symptoms,  diagnosis,  and  treatment  of  prostatitis,  see  page  725 
et  seq.) 

Vesiculitis. — Vesiculitis,  or  inflammation  of  the  seminal  vesi- 
cles, occurs  as  a  complication  of  acute  posterior  urethritis  in  a  much 
larger  percentage  of  cases  than  is  generally  imagined,  the  symptoms 
differing  so  slightly  from  those  of  inflammation  of  the  prostate  that 
the  involvement  of  the  seminal  vesicles  is  not  suspected  unless  a 
rectal  examination  is  made.  (See  section  on  Seminal  Vesicles,  page 
712.) 

Epididymitis. — From  an  anatomical  consideration  of  the  ejacu- 
latory  ducts,  vas  deferens,  and  epididymis,  it  is  easy  to  understand  how 
by  direct  continuity  inflammations  of  the  prostatic  urethra  may  travel 
to  the  epididymis. 

Epididymitis  rarely  develops  before  the  third  week  of  gonorrhoea. 
Most  of  the  cases  begin  in  the  fourth  or  fifth  week  of  the  disease. 
It  may  occur  within  three  days  of  the  onset  of  urethritis  or  not  till  a 
gleet  has  run  a  course  of  several  years. 

It  is  due  primarily  to  involvement  of  the  posterior  urethra  in  the 
gonorrhoeal  process ;  secondarily,  to  any  cause  which,  by  increasing 
the  violence  of  this  inflammation,  may  favor  its  extension  to  the  ejacu- 
latory  ducts  and  the  vas  :  neglect  of  treatment,  venereal  excitement, 
coitus,  exposure  to  cold,  drinking,  and  violent  exertion,  all  the  causes 
which  aggravate  posterior  urethritis,  also  render  more  probable  the 
onset  of  epididymitis.  Irritating  anterior  injections  during  the  acute 
stage  of  a  posterior  urethritis  frequently  cause  epididymitis.  Of  all 
these  causes  those  commonly  operative  are  neglect  of  treatment  and 
coitus. 

The  disease  is  usually  unilateral,  and  seems  to  affect  the  two  sides 
with  about  equal  frequency. 


192  GENITO-UKINAEY   DISEASES    AXD   SYPHILIS. 

In  accordance  with  the  rule  governing  gonorrhoea!  inflammations,  the 
induration  of  the  epididymis  is  Ukely  to  be  formative  rather  than  suppu- 
rative ;  hence,  abscess  is  rare.    (See  section  on  Epididymitis,  page  648.) 

EXTRAGENITAL   AND    SYSTEMIC    GONORRH(EA. 

Extragenital  gonorrhcea,  as  a  rule  secondary  to  urethral  infection 
in  the  same  individual,  exceptionally  affects  structures  other  than 
the  genital  tract,  by  predilection  those  covered  with  columnar  epithe- 
lium and  endothelium,  as  the  rectum,  peritoneum,  synovial  sheaths, 
meninges,  peri-  and  endocardium,  blood-vessels,  and  pleura.  Though 
stratified  pavement  epithelium  resists  for  a  time  gonococcal  invasion, 
gonorrhoeal  cystitis,  conjunctivitis,  and  stomatitis  are  exceptionally 
observed. 

Cystitis. — Until  the  nature  of  posterior  urethritis  was  clearly 
defined  it  was  common  to  attribute  the  symptoms  attendant  upon 
this  inflammation  to  involvement  of  the  neck  of  the  bladder.  The 
possibility  of  extension  of  posterior  urethritis  to  the  vesical  mucous 
membrane  cannot  be  denied,  and  any  one  of  the  many  causes  which 
aggravate  the  original  disease  may  occasion  such  extension.  The 
inflammation  does  not  spread  far  from  the  internal  orifice  of  the 
urethra,  being  usually  limited  rather  sharply  to  the  trigone.  In  the 
great  majority  of  cases  it  is  due  to  mixed  infection,  the  gonococci  them- 
selves apparently  not  readily  infecting  the  mucous  membrane  of  the 
bladder.  Involvement  of  the  entire  vesical  mucosa  is  extremely  rare. 
The  subjective  symptoms  are  so  like  those  of  posterior  urethritis  that 
on  these  alone  a  differential  diagnosis  can  scarcely  be  made.  (See 
chapter  on  Cystitis,  page  416.) 

This  condition  is  difficult  to  cure,  pathological  alterations  taking 
place  in  the  vesical  mucosa,  and,  indeed,  in  the  whole  thickness 
of  the  bladder  walls,  which  are  liable  permanently  to  cripple  this 
viscus. 

The  general  treatment  appropriate  to  acute  posterior  urethritis 
and  to  prostatitis  requires  no  material  alteration  when  it  becomes 
clear  that  the  vesical  mucosa  is  involved  in  the  inflammation. 

Ureteritis,  Pyelitis,  and  Nephritis. — These  complications  are 
rare,  and  can  scarcely  occur  unless  there  is  previous  vesical  disease 
as  the  result  of  urethral  stricture,  enlarged  prostate,  or  other  obstruc- 
tive cause.  The  use  of  medicaments  which  produce  acute  hyperaemia 
or  congestion  of  the  kidneys  and  their  excretory  apparatus  predisposes 
to  extension  of  inflammation  in  this  direction,  as  do  all  factors  which 
tend  markedly  to  increase  a  posterior  urethritis  and  cause  it  to  in- 
volve the  mucous  membrane  of  the  bladder,  as,  for  instance,  rough  or 


COMPLICATIONS   OF   GONOKRHOEA.  J  93 

untimely  instrumentation.  Usually  only  one  kidney  is  involved,  and 
this  sometimes  without  alteration  of  the  ureter,  although  the  latter  is 
comnionly  found  dilated  and  with  thin  walls, — in  other  words,  ex- 
hibiting the  effect  of  backward  pressure.  In  the  early  stage  of  the 
affection  the  inflammation  involves  only  the  mucous  membrane  of 
the  renal  pelvis.  This  may  be  followed  by  hydronephrosis  from 
blocking  of  the  ureter  and  consequent  atrophy  of  the  kidney,  or 
may  extend  into  the  kidney  substance  itself,  producing  either  par- 
enchymatous or  interstititial  nephritis. 

The  disease  often  undergoes  resolution,  particularly  when  it  is 
comparatively  recent,  and  when  the  cystitis  and  posterior  urethritis 
which  precede  it  have  been  cured  and  the  urethra  is  no  longer  ob- 
structed.    (For  symptoms  and  treatment,  see  these  subjects.) 

Gonorrhoea  of  the  Rectum. — Gonjrrhoeal  inflammation  of  the 
rectal  mucous  membrane  is  observed  more  frequently  in  women  than 
in  men,  mainly  because  women  are  more  exposed  to  infection  from  the 
backward  trickling  of  gonococcus-bearing  secretions  from  the  vulva 
and  vagina.     The  disease  can  be  excited  by  unnatural  practices. 

Symptoms. — The  symptoms  are  those  of  acute  inflammation. 
There  are  free  discharge  of  blood-stained  pus,  tenesmus,  painful  defe- 
cation, and  on  direct  examination  acute  redness  and  infiltration  of  the 
mucous  membrane,  with  excoriations  about  the  anal  orifice.  The 
disease  is  prone  to  become  chronic,  leaving  on  subsidence  of  the  gen- 
eral inflammation  one  or  more  localized  ulcers.  These,  if  allowed 
to  extend,  may  ultimately  cause  dense  cicatrices. 

The  diagnosis  is,  of  course,  founded  upon  the  presence  of  the  gono- 
coccus,  together  with  a  history  of  infection. 

The  treatment  consists  in  relieving  the  tenesmus  and  burning  pain 
of  the  early  stages,  in  frequent  cleansing  of  the  mucous  membrane  of 
the  affected  surfaces,  and  in  applying  astringent  and  antiseptic  medi- 
cations. 

For  the  relief  of  pain  and  tenesmus,  suppositories  containing  a 
grain  of  the  watery  extract  of  opium,  a  quarter  of  a  grain  of  cocaine, 
and  a  quarter  of  a  grain  of  belladonna  will  be  sufficient. 

The  rectum  should  be  cleaned  at  least  twice  a  day  by  means  of 
a  hot  douche  of  corrosive  sublimate  1  to  20,000,  or  protargol  1  to 
1000,  or,  if  these  solutions  occasion  severe  pain,  by  a  saturated  solu- 
tion of  boric  acid. 

When  the  acute  symptoms  have  subsided,  strong  solutions  of 
silver  nitrate  are  employed,  1  to  1000  and  1  to  500,  in  smaller  quan- 
tities. When  the  general  catarrh  is  cured,  leaving  only  ulcers  or 
hyperaemic  patches,  these  are  touched  directly  with  a  strong  solution 

13 


194  GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 

of  silver  nitrate  (ten  per  cent.),  or  with  one  of  the  other  agents  already- 
mentioned  in  the  treatment  of  chronic  gonorrhoea. 

In  some  cases,  when  a  discharge  persists,  two  per  cent,  solution 
of  alum  or  of  tannin  injected  into  the  rectum  will  prove  service- 
able. 

Gonorrhoea  of  the  mouth,  though  of  exceeding  rarity,  has  been  ob- 
served as  an  acute  stomatitis,  in  the  discharges  of  which  were  found 

gonococci. 

GONORRH(EA   OF  THE   EYE. 

GoNORRHffiAL  CONJUNCTIVITIS — Purulent  Ophthalmia;  Gonorrhceal 
Ophthalmia  ;  Acute  Blennorrhma  in  Adults. — This  is  a  violent  inflam- 
mation of  the  conjunctiva,  characterized,  in  its  usual  form,  by  great 
swelling  of  the  lids,  serous  infiltration  of  the  bulbar  conjunctiva,  and 
the  free  secretion  of  contagious  pus. 

Cause. — The  source  of  contagion  can  usually  be  traced  to  an  acute 
gonorrhoea  or  gleet,  or  to  an  eye  similarly  affected,  soiled  fingers  or 
linen  being  the  usual  means  of  transmission. 

The  gonococci  of  Neisser  are  present  in  great  abundance  during 
the  purulent  stage,  being  found  within  the  cells.  Later  they  penetrate 
the  epithelium  and  enter  the  lymph-spaces  of  the  subconjunctival 
tissue.  The  secretion  from  vaginal  leucorrhoea,  which  is  not  un- 
common in  young  girls,  may  produce  a  conjunctivitis  of  very  analo- 
gous type. 

Symptoms.— "The.  symptoms  appear  from  twelve  to  forty-eight  hours 
after  inoculation,  and  at  first  resemble  those  of  an  ordinary  catarrhal 
conjunctivitis.  They  speedily  give  place  to  great  swelling  of  the  lids 
(Fig.  66),  intense  congestion  and  chemosis  of  the  bulbar  conjunctiva, 
which  forms  a  ring  of  infiltration  around  the  cornea,  and  thickening 
of  the  palpebral  conjunctiva,  which  becomes  rough  and  dark  red  in 
color,  and  is  dotted  over  with  spots  of  ecchymosis.  (Fig.  67.)  The 
slightly  turbid  discharge  of  the  early  stage  changes  to  a  yellow  or 
greenish-yellow  pus,  which  is  secreted  in  great  quantities.  The 
vitality  of  the  cornea  is  soon  threatened,  and,  unless  the  disea.^e  is 
properly  managed,  ulcers  form,  either  small,  oval  lesions  near  the 
margin  of  the  cornea,  or  larger  ones  at  its  centre.  These  may  ter- 
minate in  healing,  or  perforation  may  take  place.  In  the  event  of  the 
latter  mishap,  incarceration  of  the  iris  in  the  wound  and  the  formation 
of  an  adherent  scar  or  leucoma  result.  This  scar  may  bulge  forward 
and  form  a  partial  anterior  staphyloma,  or,  if  the  prolapse  has  been 
an  extensive  'one,  the  whole  cornea  is  involved,  and  the  protruding 
cicatrix  is  known  as  a  total  staphyloma.  In  bad  cases  the  inflam- 
mation travels  through  all  the  tissues  of  the  eyeball,  which  passes  into 


Fill.  (>(>. 


:%:"*X  -  * 


Gonorrhceal  conjunctivitis.    Swelling  of  the  lids  aud  free  discharge. 


Fig.  67. 


Gonorrhceal  conjunctivitis.    Infiltration  of  bulljar  and  palpebral  conjunctiva. 


COMPLlCATIOlSrS   OF    GONOKEHCEA. 


195 


a  state  of  general  inflammation  or  panophthalmitis  (Fig.  68),  ending 
in  atrophy  and  shrinking  of  the  bulb. 

Gonorrhoeal  ophthalmia  neonatorum,  due  to  gonococcic  infection 
from  the  genital  tract  of  the  mother,  has  an  incubation  of  one  or  two 
days  and  is  often  bilateral.  The  inflammatory  symptoms  are  those 
characteristic  of  the  infection  in  the  adult,  but  even  more  intense  and 
rapidly  destructive. 

Gonorrhoeal  conjunctivitis  reaches  its  height  in  about  ten  days, 
and  then  gradually  subsides  in  from  one  to  two  months.  Sometimes 
it  passes  into  a  chronic  type  of  inflammation,  with  great  redness  of 

Fig.  68. 


Gonorrhoeal  conjunctivitis  passing  into  a  panophthalmitis. 

the  palpebral  conjunctiva  and  hypertrophy  of  the  papillae.  The 
right  eye  is  usually  first  affected  ;  the  left  one  may  escape  or  may 
be  inoculated ;  sometimes,  however,  both  organs  are  simultaneously 
inflamed. 

■  Diagnosis. — This  acute  infection  must  be  distinguished  from  gon- 
orrhoeal rheumatic  ophthalmia  in  the  adult  (see  table,  p.  198),  and 
from  chemical  or  traumatic  conjunctivitis  in  the  new-born  incident 
to  bichloride  vaginal  injection  of  the  mother,  or  prophylactic  silver 
instillations  to  the  eyes  of  the  infant ;  the  chemical  conjunctivitis  is 
rapid  in  onset,  brief  in  course,  and  gonococci  are  not  found  in  the 
discharge. 


196  GENITO-URINAKY   DISEASES   AND    SYPHILIS. 

Prognosis. — This  is  always  grave,  and,  unless  the  disease  is  treated 
from  its  incipiency,  corneal  scars,  or  the  more  serious  sequelae  of  per- 
foration which  have  just  been  described,  are  likely  to  result. 

Treatment. — Every  case  of  true  gonorrhceal  conjunctivitis  should  be 
isolated.  Patients  suffering  from  gonorrhoea  should  be  warned  of  the 
danger  of  infecting  their  eyes  and  the  eyes  of  those  around  them.  As 
usually  one  eye  alone  is  affected,  the  other  may  be  protected  by 
sealing  it  with  an  antiseptic  bandage  the  edges  of  which  are  made 
secure  by  fastening  along  them  strips  of  gauze  painted  with  flexible 
collodion,  or  by  the  application  of  Buller's  shield,  which  consists  of 
a  watch-glass  of  the  ordinary  form  fitted  in  a  square  piece  of  rub- 
ber adhesive  plaster,  which  is  carefully  applied  to  the  brow,  temple, 
lower  margin  of  the  orbit,  and  nose,  and  secured  with  additional 
strips  to  prevent  the  discharge  from  gettmg  under  the  edges.  The 
watch-glass  is  directly  in  front  of  the  eye  and  permits  its  constant  in- 
spection. Great  care  must  be  exercised  in  applying  this  bandage,  be- 
cause if  any  of  the  discharge  should  be  confined  beneath  it,  or  in  any 
way  should  find  entrance  under  the  edges  of  the  plaster,  the  chance 
of  infection  would  be  greater  than  without  the  bandage.  Gonor- 
rhoea! conjunctivitis  of  the  new-born  is  guarded  against  by  instill- 
ing in  each  eye  immediately  after  birth  a  few  drops  of  a  five  per 
cent,  solution  of  protargol  or  a  two  per  cent,  solution  of  silver 
nitrate.  The  curative  treatment  both  for  infants  and  adults  is  as 
follows :  During  the  earlier  stages  cold  is  the  most  useful  agent. 
This  may  be  applied  by  means  of  Leiter's  tubes,  but  it  is  more  con- 
venient to  place  upon  a  block  of  ice  square  compresses  of  patent  lint, 
which  in  turn  are  laid  upon  the  swollen  lids  and  as  frequently  changed 
as  may  be  needful  to  keep  up  a  uniform  cold  impression.  The  same 
result  is  obtained  by  using  small  bladders  containing  crushed  ice  ;  but 
they  are  not  so  comfortable  as  the  squares  of  chilled  lint. 

The  discharge  should  be  constantly  removed.  This  may  be  done 
by  irrigating  the  conjunctival  cul-de-sac  at  intervals  of  not  more  than 
half  an  hour  with  a  saturated  solution  of  boric  acid  or  a  solution  of 
bichloride  of  mercury  1  to  8000.  It  is  a  mistake  to  use  strong  solu- 
tions of  sublimate  in  the  treatment  of  this  disease,  because  they 
increase  the  liability  of  the  cornea  to  ulceration,  and,  moreover,  it  is 
not  possible  to  employ  them  in  such  strength  that  the  germicidal 
properties  of  this  drug  will  be  efficient. 

As  soon  as  the  secretion  is  free  and  creamy,  which  is  early  in 
the  disease,  silver  nitrate  is  the  best  of  all  remedies.  The  lids  should 
be  thoroughly  everted  without  pressure  upon  the  globe,  the  inflamed 
conjunctiva  freed  from  all  secretion,  and  a  solution  of  this  drug  ten  or 


COMPLICATIONS   OF   GONOEEHOEA.  ;197 

twenty  grains  to  the  ounce  applied  with  a  cotton  mop  or  camel's-hair 
brush  to  the  exposed  surfaces.  The  excess  should  immediately  be 
neutralized  with  a  solution  of  common  salt  a  teaspoonful  to  a  cup  of 
water,  flooding  the  surface  until  every  particle  of  the  white  film  pro- 
duced by  the  silver  has  been  washed  away.  The  lids  are  then  re- 
turned to  their  place.  This  application  may  be  repeated  once  in 
twenty-four  hours. 

If  a  corneal  ulcer  forms  and  is  centrally  situated,  atropine  drops 
four  grains  to  the  ounce  should  be  instilled  every  three  or  four  hours  ; 
a  marginal  ulcer,  with  a  tendency  to  perforate,  may  be  treated  in  like 
manner  with  a  solution  of  eserine  one-sixth  to  one-half  grain  to  the 
ounce,  or,  as  this  drug,  while  it  has  distinct  value  in  preventing 
sloughing  of  the  cornea,  tends  to  mcrease  the  hypersemia  of  the  iris 
and  the  tendency  to  the  production  of  iritis,  it  may  be  used  every 
four  hours  during  the  day  and  a  drop  or  two  of  the  atropine  solution 
at  night. 

If  the  chemosis  of  the  conjunctiva  is  very  great,  scarification  may 
be  tried,  and  will  occasionally  be  beneficial.  Great  swelling  of  the 
lids,  tending  by  their  pressure  to  endanger  further  the  nutrition  of  the 
cornea,  may  be  relieved  by  canthotomy, — that  is,  by  cutting  through 
the  external  commissure  of  the  affected  eye. 

During  the  stage  of  corneal  ulceration,  should  it  occur,  the  cold 
applications  previously  described  may  be  substituted  by  hot  fomenta- 
tions applied  by  means  of  squares  of  antiseptic  gauze  wrung  out  of 
carbolized  water  of  a  temperature  of  120°  F.  and  frequently  changed. 
These  applications  are  useless  unless  they  are  really  hot. 

Many  other  drugs  in  addition  to  those  named  have  been  used  for 
irrigating  the  conjunctival  cul-de-sac.  Of  these,  the  most  important 
are  mercuric  cyanide  1  to  1 500,  protargol  1  to  2000,  hydrogen  per- 
oxide, aluminium  sulphate  eight  grains  to  the  ounce,  carbolic  acid 
one-half  to  five  per  cent.,  and  potassium  permanganate.  Of  the  last- 
named  drug  a  tepid  solution  1  to  5000  should  be  prepared,  and  the 
conjunctival  cul-de-sac  freely  flushed  twice  a  day,  at  least  one  litre 
being  employed  at  each  irrigation.  The  irrigations  are  best  given 
with  the  aid  of  a  special  laveur,  although  an  ordinary  irrigating  appa- 
ratus is  useful. 

During  the  entire  course  of  the  treatment  the  lids  should  be  kept 
greased  with  pure  vaseline,  which  should  also  be  freely  introduced 
within  the  conjunctival  cul-de-sac. 

Depletion  is  sometimes  practised,  but,  unless  the  indications  for 
canthotomy  are  present,  its  value  is  questionable.  *  The  same  may  be 
said  of  the  practice,  once  common,  of  beginning  the  treatment  by 


198  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

bringing  the  patients  under  the  influence  of  mercury.  Usually  they 
are  debilitated,  and  supporting  treatment — quinine,  iron,  strychnine, 
and  milk  punch — is  essential.  If  the  pain  is  severe,  there  is  no  ob- 
jection to  the  use  of  morphine  or  opium,  the  latter  drug  having  a  good 
influence  on  the  sloughing  process  in  the  cornea. 

Rheumatic  Gonorrhceal  Ophthalmia. — This  disease  is  occasion- 
ally seen  during  gonorrhcea,  and  does  not  depend  upon  the  intro- 
duction into  the  eye  of  infecting  material  from  the  urethra.  It  is  apt  to 
occur  in  patients  vvrho  suffer  from  articular  complications.  It  is  bilat- 
eral, mild  in  character,  and  resembles  a  moderate  catarrhal  conjunc- 
tivitis.    Sometimes  iritis  complicates  it. 

The  treatment  of  ordinary  catarrhal  conjunctivitis  is  indicated  unless 
there  be  iritis,  and  then  the  measures  elsewhere  described  are  suitable. 

Virulent  GonorrJiceal  Conjunctivitis.  Rheumatic  Gonorrhoe.al  Ophthalmia. 

A  rare  but  serious  affection.  More  common  but  less  serious. 

Essential  cause  is  inoculation  with  gon-  Probably  the  causative  agent  comes  from 
orrhoeal  pus  from  without;  violently  within  through  the, blood.  Probably 
contagious  ;  gonococci  abundant  in  metastatic  ;  gonococci  not  found  ex- 
pus,  cept  in  the  later  stages  and  then  with 

difficulty. 

Not  dependent  on  or  necessarily  coin-  Is  coincident  with  gonorrhoeal  arthritis, 
cident  with  rheumatoid  affections. 

May  affect  subjects  not  afflicted  with  ure-  Occurs  only  in  patients  with  gonorrhoeal 

thritis,  as  in  infants  (ophthalmia  neon-  urethritis, 
atorum). 

Usually  affects  only  one  eye,  but  may  be  Commonly  the  disease  is  bilateral  in  the 

transferred  to  the  other.  beginning  ;  or  rarely  may  move  from 

one  eye  to  the  other. 

The  conjunctiva  is  always  the  structure  Disease  usually  starts  in  the  iris  mem- 

primarily  involved.  brane  of  Descemet  and  may  later  in- 
volve the  oculo-palpebral  conjunctiva. 

No  tendency  to  recur  in  subsequent  ure-  Marked  tendency  to  recur, 
thritis. 

Prognosis  extremely  grave  ;  often  loss  of  Prognosis    favorable  ;    no    loss    of  eye- 

the  eyesight.  sight. 

Treatment  must  be  specific  and  active.  Treatment  need  be  only  symptomatic. 

The  epidemic  conjunctivitis  due  to  the  Koch-Weeks  bacillus  or  to 
the  pneumococcus  affects  both  eyes  with  but  moderate  severity,  is  usu- 
ally observed  in  more  than  one  member  of  a  family  and  fails  to  show 
gonococci  in  the  moderate  discharge. 

GONORRHOEAL    RHEUMATISM. 
Gonorrhoeal  rheumatism,  a  local  expression  of  gonococcic  septi- 
caemia, commonly  affects  the  joints.     It  may,  however,  involve  the 


COMPLICATIONS   OF   GONORKH(EA.  199 

bones,  tendons,  nerves,  bursae,  pericardium,  endocardium,  and  menin- 
ges of  the  cord.  It  is  due  to  systemic  poisoning  by  the  specific  micro- 
organisms or  by  the  ordinary  bacteria  of  suppuration  and  the  toxal- 
bumens  formed  by  these  germs.  When  it  is  caused  by  gonococci 
carried  from  the  urethra  or  from  a  wound  into  the  circulation  and 
lodged  at  remote  points,  the  inflammation  is  fibrous  and  adhesive  in 
type. 

Finger  in  a  fatal  case  of  gonorrhoeal  rheumatism  discovered  gono- 
cocci in  the  vegetations  of  the  endocarditis.  There  was  also  myo- 
carditis, due  to  the  presence  of  these  germs. 

When  there  is  free  pus-formation  the  ordinary  pyogenic  microbes 
are  found. 

The  disease  may  begin  before  the  third  week  of  the  urethritis, 
though  it  commonly  develops  much  later. 

In  the  order  of  frequency  the  knee,  ankle,  wrist,  and  elbow  are 
the  joints  commonly  involved.  Usually  more  than  one  joint  is  in- 
flamed at  a  time,  though  in  about  one-third  of  all  cases  the  disease  is 
monarticular. 

It  develops  in  about  two  per  cent,  of  all  cases  of  urethritis,  and 
is  far  more  frequently  observed  in  men  than  in  women.  It  may 
complicate  gonorrhoea  of  any  mucous  surface, — the  conjunctiva,  for 
instance. 

Arthritis  is  the  commonest  manifestation  of  gonorrhoeal  rheuma- 
tism. It  may  be  ushered  in  by  general  rheumatic  pains,  but  more 
commonly  is  characterized  by  rather  sudden  swelling,  pain,  tender- 
ness, and  redness  of  the  affected  articulation.  There  is  synovial  exu- 
dation, with  fixation  of  the  joint  in  the  position  which  most  relaxes 
its  synovial  investment.     There  is  moderate  fever.     Pain  is  severe. 

These  acute  symptoms  usually  last  for  several  days.  The  fever 
then  subsides,  and  complete  resolution  may  quickly  follow,  or  the 
patient  may  suffer  for  weeks  or  months  from  swelling,  tenderness,  and 
harassing  pain,  subject  to  occasional  exacerbations  in  accordance  with 
the  condition  of  the  urethra.  Such  joints  commonly  remain  partly 
or  completely  stiff.  Rarely  suppuration  takes  place,  characterized  by 
constitutional  and  local  symptoms  of  pus-formation,  resulting,  if  the 
patient  recovers,  in  ankylosis  of  the  joint. 

Sometimes  the  chronic  inflammation  produces  a  condition  of  hy- 
drarthrosis, attended  with  limitation  of  motion,  but  otherwise  causing 
little  pain  and  but  slight  disability.  The  effusion  usually  undergoes 
absorption.  Occasionally  it  lasts  for  weeks  or  months,  causes  stretch- 
ing of  the  ligaments,  and  finally  preternatural  mobility  and  profound 
alteration  in  the  joint. 


200 


GENITO-UEINAKY   DTSEASES   AND   SYPHILIS. 


Symptoms. — There  is  absolutely  no  characteristic  feature  of  the 
joint  affection  which  wijl  enable  the  surgeon,  from  a  local  examina- 
tion, to  distir.guish  gonorrhoeal  mflammation  from  the  lesions  of 
ordinary  rheumatism.  In  making  a  diagnosis,  however,  the  following 
points  should  be  borne  in  mind.  In  gonorrhoeal  rheumatism  there  is 
a  preceding  history  of  urethritis,  and  the  severity  of  the  rheumatic 
attack  varies  in  proportion  to  the  exacerbations  and  remissions  of 
the  urethral  inflammation.  The  disease  rarely  pursues  the  acute 
course  observed  in  ordinary  rheumatism,  but  rather  has  a  tendency 
to  become  chronic,  and  after  it  has  once  occurred  is  prone  to  relapse 
in  case  of  new  infection  of  the  urethra. 

When  several  joints  are  affected  the  distinction  between  gonor- 
rhoeal arthritis  and  that  due  to  rheumatism  is  exceedingly  difficult  to 
make.  In  the  former  case,  however,  but  few  joints  are  involved, 
rarely  more  than  two  or  three,  and  in  these  the  inflammation  does 
not  appear  synchronously,  but  one  inflames  after  the  other.  The 
fever  is  never  very  high,  except  in  the  rare  cases  when  suppura- 
tion occurs,  nor  is  sweating  so  pronounced  a  symptom  as  in  rheu- 
matism. 

Occasionally  the  gonorrhoeal  rheumatism  takes  the  form  of  peri- 
arthritis. The  symptoms  are  much  the  same  as  those  of  arthritis, 
except  that  there  is  no  exudation  into  the  j  oint-cavity ,  and  the  red- 
ness, oedema,  pain,  and  tenderness  are  somewhat  more  marked.  It 
commonly  terminates  in  resolution,  but  may  cause  ankylosis. 

The  following  tabulation  of  the  symptomatology  of  rheumatic  fever, 
chronic  rheumatism,  gout,  and  gonorrhoeal  arthritis  may  prove  ser- 
viceable. 


Rheumatic  Fever.  Chronic  Rheumatism.  Oout. 

Most  frequent  in  young     Most  frequent  in  older     Most  frequent  in  older 
adults.  persons.  persons. 

Gonococci  are  not  found  in  discharge. 

Urethral  discharge  comparatively  rare. 


Family  history  may  be 

positive. 
Etiologic    relationship 

to  cold  and  damp. 

Onset  sudden. 

Constitutional  phe- 
nomena severe,  high 
fever,  and  often  chill. 

Alv(  ays  polyarticular 
and  virandering  from 
joint  to  joint. 


Family    history    often 

positive. 
Symptoms      distinctly 

influenced        by 

weather. 
Onset  insidious. 

Constitutional  phe- 
nomena mild  or  ab- 
sent. 

Usually  polyarticular. 


Family  history  usually 

positive. 
Symptoms    related    to 

diet. 

Onset  sudden  with  per- 
haps prodromes. 

Constitutional  phe- 
nomena mild. 

Usually  monarticular. 


Gonorrhceal  Arthritis. 

Most  frequent  in  young 
adults. 

Gonococci  are  found  in 
urethral  discharge. 

Urethral  discharge  al- 
ways present,  though 
it  may  be  found  only 
in  the  urine. 

Family  history  nega- 
tive. 

Primary  relationship  to 
urethra. 

Onset  sudden,  no  pro, 
dromes. 

Constitutional  phenom- 
ena mild  and  tran- 
sient. 

Nearly  always  monar- 
ticular. 


COMPLICATIONS   OF   GONOREHCEA. 


201 


Rheumatic  Fever. 
Predilection  for   large 
joints,  a  number  at 
the  same  time. 


Distinctly  acute  inflam- 
matory affection  with 
great  tenderness,  red- 
ness, heat,  and  fluc- 
tuation. 

No  tophaceous  deposits. 


Acid  sweats  marked. 


Chronic  Rheumatism. 
Large  joints. 


Mildly  inflammatory, 
rarely  marked  hy- 
drarthrosis. 


No  true  tophaceous  de- 
posits. 

Less  marked  but  often 


Gout. 


present. 
Cardiac   Complications     Less  frequent. 

frequent. 
Urine      loaded      with     Urine  is  less  character- 

urates  and  uric  acid        istic. 

crystals. 


Great  toe. 


Never  hydrarthrosis. 


Always  tophaceous  de- 
posits in  joints  or 
ears. 

Not  so  conspicuous. 

Myocarditis     and    ar- 

terio-sclerosis. 
Urine  loaded  with  uric 

acid  and  urates. 


The  eye  and  usually  the  bursae  and  tendons  escape  in  these  three. 


Relapses  are  frequent,  and  may  or  may  not  be  associated  with  recurrence 
of  urethral  discharge. 


Disease  is  cured  by  sali- 
cylates and  anti- 
rheumatic treatment. 


These  remedies  are  use- 
ful combined  with 
tonics. 


Dietetic,  hygienic,  and 
medicinal  treatment 
are  effectual. 


Gonorrhoeal  Arthritis. 

Knee  most  frequently 
involved,  may  attack 
other  joints,  but  gen- 
erally only  one  at  a 
time. 

Usually  hydrarthrosis 
slowly. 


Never  tophaceous  de- 
posits. 

Never  present. 

Cardiac  complications 
rare. 

Urine  contains  clap 
shreds,  but  is  not  ex- 
cessively acid. 

Frequent  eye  complica- 
tions, bursitis,  and 
tenosynovitis. 

Relapses  are  more  or 
less  dependent  on  the 
condition  of  the  ure- 
thra. 

Internal  remedies  are 
useless ;  the  urethritis 
must  be  cured  by  local 
remedies. 


Baer  calls  attention  to  an  affection  characterized  by  a  painful  bony 
outgrowth  from  the  tubercle  of  the  os  calcis,  lying  just  in  front  of  the 
attachment  to  the  plantar  fascia.  Pain,  the  chief  symptom,  is  referred 
directly  to  the  attachment  of  the  plantar  fascia  with  the  os  calcis,  and 
is  elicited  only  by  pressure.  The  patient  usually  walks  on  the  ball  of 
the  foot.  The  affection  appears  in  young  males  in  the  first  year  of  a 
chronic  gonorrhoea.  It  is  bilateral.  The  diagnosis  is  based  on  the  radio- 
graph. Treatment  is  by  operation  and  removal  of  the  bony  outgrowth 
and  is  entirely  successful.  Such  growths  occur  in  those  who  have 
never  had  gonorrhoea. 

Tenosynovitis. — This  affection  develops  usually  after  the  acute  stage 
of  gonorrhoea  has  passed.  The  involved  tendon  exhibits  over  its  course 
tenderness,  redness,  oedematous  swelling,  and  crepitation  or  distinct 
fluctuation.  The  tendons  most  commonly  involved  are  the  exten- 
sors of  the  fingers,  the  flexor  of  the  thumb,  and  the  tendons  of  the  toes. 

As  complications  of  gonorrhoea,  rheumatism,  pericarditis,  endocar- 
ditis, pleuritis,  and  meningitis  develop  exceptionally ;  myalgia  and 
neuralgia  are  occasionally  pronounced. 

Phlebitis. — Heller  notes  that  gonorrhoeal  phlebitis  is  commonest  in 
men  in  the  fourth  or  fifth  week  of  a  first  attack.  The  internal  saphe- 
nous vein  is  most  frequently  involved ;  next  the  common  femoral, 


202  GENITO-UKINARY   DISEASES   AIS'D    SYPHILIS. 

the  superficial  veins  of  the  abdominal  parietes,  the  veins  of  the  corpora 
cavernosa,  sometimes  those  of  the  arm.  There  are  acute  pain  and  fever. 
Until  the  external  veins  are  involved,  forming  indurated  cords,  the  diag- 
nosis cannot  be  made.  Two  out  of  the  twenty-six  cases  died, — one  of 
embolus  and  one  of  sepsis.  One  required  amputation  at  the  thigh. 
The  treatment  is  by  rest,  evaporation,  lotions,  and  later  by  absorbents. 

Diagnosis. — The  gonococcic  nature  of  such  affections  as  pericarditis, 
pleuritis,  and  meningitis  can  be  determined  only  by  the  discovery  of 
these  organisms  in  the  blood,  even  though  a  gonococcal  urethritis 
be  present.  This  requires  the  removal  by  veno-puncture  of  about 
twenty  cubic  centimetres  of  blood  and  its  immediate  culture,  since  the 
diplococcus  intracellularis  meningitidis,  the  micrococcus  catarrhalis, 
and  some  others  decolorize  by  the  Gram  method. 

The  treatment  of  gonorrhceal  rheumatism  depends  upon  the  cure 
of  the  local  infection,  and  the  best  prophylactic  resort  is  urinary  anti- 
septics. Salicylic  acid  and  the  salicylates  should  be  tried,  as  occa- 
sionally the  attack  is  ordinary  rheumatism,  and  if  this  be  mild  in  type, 
involving  but  few  joints,  a  differential  diagnosis  in  the  presence  of 
chronic  gonorrhoea  is  scarcely  possible.  Potassium  iodide  is  some- 
tmies  serviceable,  while  full  doses  of  salol  are  usually  beneficial,  and 
in  chronic  and  obstinate  cases  quinine  pushed  to  ils  physiological  limit, 
together  with  bichloride  of  mercury,  one-sixtieth  of  a  grain  thrice  daily, 
will  sometimes  act  favorably. 

For  the  acute  stage  absolute  rest,  with  the  joint  in  the  most  com- 
fortable position,  the  application  of  cold,  preferably  in  the  form  of  an 
ice-bag,  and  such  pressure  as  can  be  comfortably  borne,  and  constitu- 
tional treatment  for  fever,  are  the  best  therapeutic  procedures.  When 
the  acute  stage  has  passed,  the  affected  joints  should  be  wrapped  in  an 
ointment  composed  of  mercurial  ointment,  belladonna  ointment,  com- 
pound iodine  ointment,  and  cosmoline,  equal  parts  of  each.  They 
should  be  bandaged  firmly,  and  vigorously  massaged  once  daily,  small 
doses  of  iodide,  or  of  quinine  and  bichloride,  being  continued. 

When  a  large  joint,  such  as  the  knee,  is  markedly  distended  by  an 
intra-articular  effusion,  causing  intense  suffering,  incision,  evacuation 
of  the  fluid  contents  and  fibrinous  bodies,  irrigation  with  carbolic  solu- 
tion 1  to  500,  followed  by  closure  with  or  without  drainage,  afford 
immediate  relief  and  often  accomplish  a  permanent  cure.  Even  though 
there  be  little  or  no  pain,  persistent  large  effusions  should  be  thus 
treated.    In  suppurative  cases  the  operative  indications  are  imperative. 

The  source  of  the  continued  toxaemia,  which  is  often  an  initial 
symptom  in  chronic  cases,  must  be  sought  and  removed,  and  mas- 
sage of  the  prostate  and  vesicles,  or  drainage  or  excision  of  the  latter, 
may  be  indicated. 


CHAPTER   VI. 

STRICTURE    OF    THE    URETHRA. 

A  STRICTURE  is  a  temporary  or  permanent  narrowing  of  the  urethral 
canal,  .caused  by  organic  changes  in  the  tissues  which  make  up  its 
walls,  or  by  muscular  spasm. 

Strictures  may  be  congenital  or  acquired. 

Congenital  stricture  is  extremely  rare,  except  at  the  meatus  or  in 
its  immediate  vicinity.  Even  these  narrowings  are  often  the  result 
of  infantile  balanoposthitis,  and  thus  not  really  congenital.  A  nar- 
rowing of  the  meatus,  reducing  it  almost  to  pin-point  size,  may  exist 
from  birth  without  giving  rise  to  appreciable  difficulty,  and,  unless 
some  urinary  symptoms  appear,  requires  no  treatment. 

The  normal  narrowing  at  the  meatus  is  of  physiological  impor- 
tance in  favoring  the  projection  of  a  strong,  smooth  stream  of  urine 
and  the  vigorous  ejaculation  of  the  sperm :  hence  free  division  of  the 
meatus  should  not  be  advised  on  insufficient  grounds.  Not  infre- 
quently the  operation  may  leave  the  patient  with  an  artificial  balano- 
hypospadia  and  diminished  projectile  force. 

Congenital  strictures  should,  however,  be  operated  upon  promptly 
when  urinary  symptoms  arise  which  reasonably  can  be  traced  to 
them,  or  when  they  interfere  with  the  proper  treatment  of  more 
deeply  seated  morbid  conditions  of  the  urethra  or  of  the  bladder. 

Acquired  stricture  is  classified  in  accordance  with  its  pathology 
under  these  general  headings  : 

1.  Inflammatory. 

2.  Spasmodic. 

3.  Organic  ;  (a)  of  large  calibre  ;  (6)  of  small  calibre. 

1.  Inflammatory  stricture  is  due  to  an  acute  catarrhal  inflam- 
mation with  recent  soft  exudate,  causing  swelling  of  the  mucous 
membrane  and  encroachment  on  the  urethral  calibre.  It  is  of  short 
duration,  and  never  causes  retention,  except  when  complicated  by 
muscular  spasm.  It  is  often  the  first  step  in  the  formation  of  organic 
stricture. 

Ti^eatment. — The  treatment  is  that  appropriate  to  acute  anterior 
urethritis.  The  term  inflammatory  stricture  is  misleading,  since  some 
authors  thus  designate  true  organic  strictures, — i.e.,  those  which  uiti- 

203 


204  GENITO-UKINARY    DISEASES  AND   SYPHILIS. 

mately  result  from  chronic  inflammation  with  formation  of  fibrous 
tissue. 

2.  Spasmodic  stricture  is  a  temporary  narrowing  or  obliteration 
of  the  urethra,  due  to  contraction  of  the  involuntary  or  voluntary 
muscles  investing  it.  This  contraction  is  either  reflex  or  psychical  in 
its  origin,  and  the  compressor  urethrae  is  usually  the  muscle  at  fault. 

Reflex  muscular  spasm  commonly  depends  on  irritation  trans- 
mitted from  some  hyperaemic  point  of  the  urethra,  as  from  the  actively 
inflamed  mucous  membrane  of  the  posterior  urethra,  or  from  a  patch 
of  granular  urethritis  situated  in  or  near  the  bulb.  More  rarely  it 
may  arise  from  irritation  at  a  greater  distance,  as  from  fissure  of  the 
anus,  hemorrhoids,  worms,  cancer  of  the  rectum,  etc. 

Among  the  causes  of  spasm  may  be  mentioned  strongly  acid  or 
irritating  conditions  of  the  urine,  as  in  cantharidal  poisoning  or  the 
uric  acid  diathesis,  and  urethral  hyperassthesia  from  sexual  excess. 
Organic  stricture  is  the  usual  predisposing  factor  in  the  development 
of  the  symptoms  of  spasmodic  stricture. 

The  retention  of  urine  incident  to  overdistention  of  the  bladder,  or 
acute  fevers,  or  surgical  operations,  especially  those  upon  the  anus  and 
the  rectum,  is  probably  as  often  the  result  of  vesical  inhibition  as  of 
urethral  spasm,  although  it  is  usually  attributed  to  the  latter. 

Numerous  cases  have  been  reported  in  which  a  more  or  less  per- 
sistent spasm  has  been  attributed  to  a  small  meatus,  since  this  was 
relieved  by  meatotomy ;  but  it  must  be  remembered  that  spasmodic 
stricture  is  particularly  apt  to  occur  in  nervous,  excitable,  irritable 
young  men,  allied  in  type  to  hysterical  women,  and  that  in  such 
patients  any  marked  mental  impression  may  cause  a  disappearance  of 
existing  symptoms.  A  case  has  been  reported  in  which  all  the  symp- 
toms of  deep  urethral  obstruction  existed  for  ten  years,  and  were  re- 
lieved immediately  and  permanently  by  a  single  catheterization,  a 
result  which  would  doubtless  have  been  attributed  to  a  meatotomy 
if  that  had  been  required  as  a  prehminary  operation.  If  the  meatus 
is  too  small  to  admit  a  good-sized  sound,  in  the  presence  of  other- 
wise inexplicable  urinary  symptoms  a  cutting  operation  is  clearly 
indicated. 

Spasmodic  stricture  due  to  psychical  cause  is  instanced  by  the  in- 
hibiting effect  which  shame  or  even  a  sense  of  hurry  exerts  over  the 
function  of  micturition. 

Diagnosis. — The  diagnosis  of  spasmodic  stricture  is  founded  upon 
the  sudden  onset  of  either  dysuria  or  retention  of  urine  without  inflam- 
matory symptoms  and  without  preceding  symptoms  of  urethral  ob- 
struction.    Sometimes  the  stream  is  irregularly  interrupted,  a  condition 


STKICTUKE   OF    THE   UKETHRA.  205 

designated  as  stuttering  micturition.  The  introduction  of  a  full-sized 
metal  instrument  may  be  resisted  at  first,  but  on  gentle  continued 
pressure  the  contracted  muscles  may  be  felt  to  yield  and  the  instrument 
readily  slips  into  the  bladder. 

Treatment. — The  treatment  of  spasmodic  stricture  varies  in  accord- 
ance with  the  cause.  When  symptoms  recur,  careful  search  always 
should  be  made  for  organic  stricture ;  this,  if  cured,  will  be  followed 
by  disappearance  of  the  tendency  to  spasm.  Every  pathological  con- 
dition about  the  genitaha  or  rectum  should  be  corrected,  and  in  the 
absence  of  contra-indications  full-sized  sounds  should  be  passed  at 
regular  intervals. 

When  spasmodic  stricture  is  complicated  by  retention,  the  patient 
should  be  put  in  a  hot  general  bath  (106°  to  110°  F.),  and  directed 
to  urinate  while  therein.  A  hot  sitz-bath  is  equally  efficacious, 
but  should  be  continued  not  over  fifteen  minutes.  If  at  the  end  of 
this  time  the  bladder  has  not  been  emptied,  the  patient  should  be 
thoroughly  dried,  put  to  bed,  and  given  suppositories  containing 
opium  and  belladonna,  or  hypodermic  injections  of  morphine.  These 
palliative  measures  should,  however,  never  be  persisted  in  when  the 
bladder  is  greatly  distended, — i.e.,  is  readily  perceptible  on  suprapubic 
percussion.  The  possible  remote  effects  of  overdistention  of  the  blad- 
der are  far  more  to  be  dreaded  than  the  slight  discomfort  attendant 
on  the  passage  of  an  instrument :  hence  if  the  distention  is  great  and 
the  hot  bath  fails  to  give  relief,  catheterization  should  be  practised  at 
once.  A  soft  rubber  or  an  English  gum  catheter  should  be  used  first ; 
if  these  fail,  a  metal  instrument  should  be  introduced.  It  must  be 
borne  in  mind  that  under  these  circumstances  the  bladder  is  pecu- 
liarly liable  to  become  infected  ;  therefore  the  catheterization  must  be 
practised  with  the  observance  of  all  the  antiseptic  precautions  cus- 
tomary in  major  operations.  The  surgeon's  hands  must  be  thoroughly 
cleansed,  the  instrument  sterile,  the  glans  and  meatus  disinfected,  and 
the  anterior  urethra  previously  flushed  out  with  an  antiseptic  solution. 

3.  Organic  Stricture. — This,  in  the  vast  majority  of  cases,  is  due 
to  a  preceding  urethritis  or  to  traumatism,  though  a  chancroid,  chan- 
cre, or  ulcer  due  to  lodgement  of  a  foreign  body  may  subsequently  be 
followed  by  cicatricial  narrowing.  Gonorrhoeal  urethritis  is  by  far  the 
most  common  cause. 

Organic  stricture  may  occur  in  persons  of  any  age,  but  is  most 
frequent  between  the  ages  of  twenty  and  forty-five.  Women  are  not 
entirely  exempt.  Gonorrhcsal  stricture  is  said  to  occur  less  frequently 
in  negroes  than  in  white  men,  the  proportion  being  about  one  stric- 
ture to  twenty-three  cases  of  gonorrhoea  in  the  negro,  while  in  the 


206  GENITO-UPvINAEY   DISEASES  AND   SYPHILIS. 

white  man  it  is  about  one  in  eight.  The  longer  the  duration  of  the 
attack  of  gonorrhoea  the  more  liable  is  the  patient  to  have  a  stricture. 
The  intensity  of  the  attack  is  also  of  some  importance  in  this  regard. 
The  supposed  development  of  stricture  because  of  too  rapid  cure  of 
gonorrhoea  is  a  popular  myth.  The  more  speedy  the  cure  the  less 
likely  are  strictures  to  form,  nor  have  strong  irritating  injections  any 
effect  on  the  production  of  stricture  unless  they  cause  complications, 
such  as  abscess,  or  prolong  the  inflammation. 

Inflammations  of  the  urethra  are  peculiarly  apt  to  become  chronic, 
for  several  reasons.  The  canal  affords  periodical  passage  to  the 
urine,  which  is  liable  to  become  an  actual  irritant  by  reason  of 
changes  in  its  composition  ;  erection,  reflexly  excited  by  inflammation, 
intensely  congests  the  urethral  vessels,  which,  moreover,  are  especially 
abundant,  and  are  prone  to  engorgement  from  the  dependent  position 
of  the  penis  and  the  absence  of  extra-vascular  support  incident  to  the 
loose  character  of  the  spongy  tissue.  All  these  factors  favor  the  per- 
sistence of  congestion  after  a  first  attack  of  urethritis.  The  approxi- 
mation of  the  mucous  surfaces  of  the  urethral  walls,  normal  during 
the  intervals  between  micturition,  is  also  unfavorable  to  the  disap- 
pearance of  the  last  traces  of  inflammation.  Finally  the  gonococcus 
exhibits  a  tendency  to  establish  itself  in  the  deeper  layers  of  the 
mucous  hning,  and  particularly  in  the  follicular  and  glandular  ducts, 
where  it  is  inaccessible  to  direct  treatment. 

Harrison  holds  that  in  chronic  granular  urethritis  the  urethral 
epithelium  becomes  so  damaged  at  one  or  more  spots  as  a  consequence 
of  prolonged  inflammation  that  it  permits  the  escape  of  minute  quan- 
tities of  urine  into  the  tissues  composing  and  surrounchng  the  urethra. 
To  prevent  urine  soaking  farther  into  these  tissues,  inflammatory  exu- 
dation is  excited,  and  barriers  of  lymph,  which  ultimately  become 
organized,  are  thrown  out  opposite  the  places  where  the  leakages  take 
place.  Thus  splints  of  plastic  tissue  are  formed  corresponding  to  the 
spot  or  spots  v.-here  the  epithelium  has  been  most  damaged  by  the 
persisting  inflammation. 

Oberlander  demonstrates  the  existence  of  two  chief  forms  of 
chronic  urethritis :  (1)  that  in  which  the  infiltration  of  the  mucous 
membrane  is  diffuse  and  superficial  and  the  glandular  elements  are 
not  involved,  and  (2)  that  in  which  the  glands  of  Littre  are  markedly 
affected.  Neelson  has  confirmed  these  views  by  a  long  series  of  au- 
topsies, which  show  that  the  glandular  affection  is  extremely  per- 
sistent, and  easily  recognizable  even  when  cadaveric  maceration  has 
destroyed  the  evidences  of  change  in  the  mucosa  and  of  the  epithelial 
proliferation. 


STRICTURE   01    THE    URETHRA. 


207 


The  rapidity  of  stricture  development  is  dependent  upon  the 
nature  of  the  original  lesion.  In  case  of  rupture  of  the  urethra  nar- 
rowing of  the  lumen  of  this  canal  begins  from  the  time  the  wound 
cicatrizes  ;  that  is,  usually  within  a  few  weeks.  In  the  case  of  gonor- 
rhoea, however,  the  process  is  much  more  slow.  The  infiltration 
caused  by  this  disease,  unless  complicated  by  periurethral  abscess,  is 
essentially  chronic.  It  is  always  a  matter  of  months,  and  usually  of 
years,  before  this  infiltration  undergoes  sufficient  organization  to  en- 
croach seriously  upon  the  calibre  of  the  urethra.  It  may  be  said  in 
general  terms  that  a  stricture  rarely  develops  within  one  year  of  the 
beginning  of  an  attack  of  gonorrhoea.  Guyon  holds  that  the  greatest 
number  of  strictures  occur  four  to  ten  years  from  the  beginning  of  the 
original  urethritis. 

Prolonged  erection,  excessive  coitus,  and  masturbation  have  been 
regarded  as  competent  causes  of  stricture,  especially  by  the  ardent 
behevers  in  strictures  of  large  calibre,  who  find  this  lesion  in  nearly 
every  urethra,  often  without  a  history  of  gonorrhoea  or  of  any  of  the 
sources  of  irritation  previously 
mentioned.  Theoretically  stric- 
ture is  possible  from  such  causes, 
but  practically  it  is  of  the  greatest 
rarity. 

Traumatic  stricture  follows  such 
wounds  and  contusions  of  the  peri- 
neum as  have  caused  partial  or 
complete  laceration  of  the  urethra. 
Kicks  in  the  perineum,  falls  astride 
of  a  resistant  body,  and  fractures 
of  the  pelvis  often  cause  such  rup- 
tures. "  Fracture  of  the  penis," — 
that  is,  a  sudden  twist  or  bend  of 
the  erect  penis,  which  causes  sub- 
cutaneous rupture  of  the  erectile 
tissue ;  "  breaking  a  chordee," — i.e., 
violently  straightening  the  curve 
incident  to  the  inflammatory  infil- 
tration of  the  urethra  and  peri- 
urethral tissues  ;  injuries  due  to  the 
rough  and  clumsy  use  of  urethral  instruments ;  surgical  treatment  of 
previously  existing  strictures,  such  as  incision,  excision,  cauterization, 
and  electrolysis, — all  these  causes  may  produce  traumatic  strictures. 

Clinical  Forms  of  Stricture. — The  strictured  part  of  the  urethra 


Linear  strictures,  ^.glans;  B,  grlandular 
urethra :  C,  spongy  body ;  D,  urethra  dilated 
behind  the  stricture;  E,  linear  stricture;  6, 
linear  stricture  less  developed ;  a,  cavernous 
body.    (Voillemier.) 


208 


GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 


varies  greatly  in  extent,  from  a  mere  cord-like  band,  linear  stricture 
(Fig.  69),  to  one  slightly  broader,  annular  stricture  (Fig.  70),  and  from 
that  to  a  contraction  which  may  involve  two  or  three  inches  of  the 


Fig.  70. 


Fig.  71. 


Annular  stricture. 


Tortuous  stricture. 


canal,  changing  it  into  a  devious,  irregular  channel,  tortuous  stricture. 
(Fig.  71.) 

Strictures  may  also  be  classified  as :  1.  Soft  or  recent,  the  sub- 
epithelial exudate  not  yet  having  become  extensively  organized  into 
connective  tissue.  Under  this  heading  would  be  included  strictures 
of  large  calibre  and  those  cases  of  chronic  urethritis  which  resemble 
stricture  or  constitute  its  first  stage.     2.   Cicatricial,  characterized  by 


STRICTURE    OF    THE    URETHRA.  209 

an  ill-defmed  mass  of  fibrous  tissue  often  cartilaginous  in  consist- 
ency. Ttie  traumatic  strictures  are  made  up  entirely  of  fibrous  tis- 
sue ;  the  gonorrhoeal  strictures  still  exhibit  traces  of  the  original 
structure  of  the  parts. 

There  is  also  a  peculiar  form  of  contraction  of  the  meatus,  which 
appears  as  a  diffuse  induration  of  the  mucous  membrane,  scar-like  in 
appearance  and  cartilaginous  in  consistency ;  this  extends  outward  on 
the  glans  and  for  some  distance  inward ;  it  is  apparently  a  form  of 
scleroderma.  Local  treatment  is  of  Httle  use,  but  there  is  often  some 
spontaneous  improvement  after  a  considerable  lapse  of  time. 

Strictures  are  further  classified  as, — 

1.  Simple, — that  is,  exhibiting  only  the  symptoms  and  reactions 
characteristic  of  the  majority  of  strictures. 

2.  Irritable. — Instrumentation  causes  unusually  severe  pain,  is 
sometimes  followed  by  hemorrhage,  and  excites  undue  local  inflam- 
mation or  occasions  urethral  fever. 

3.  Resilient,  Contractile,  or  Recurring. — The  stricture  if  untreated 
steadily  becomes  tighter.  Even  if  it  can  be  dilated,  it  again  contracts 
so  rapidly  that  this  method  of  treatment  is  without  benefit. 

In  accordance  with  the  extent  to  which  they  narrow  the  urethra, 
strictures  are  either  of  large  calibre  or  of  small  calibre. 

The  terms  permeable  and  impermeable  indicate  whether  or  not  an 
instrument  can  be  passed  through  the  narrowing. 

Every  stricture  following  a  urethritis  must  at  some  time  have  been 
a  stricture  of  large  calibre,  but  just  when  such  a  stricture  becomes  a 
pathological  factor  and  is  able  to  give  rise  to  symptoms  is  an  unsettled 
point.  There  is  no  fixed  calibre  of  the  urethra,  and  the  size  of  the 
meatus  is  not  a  reliable  index  as  to  the  diameter  of  the  canal  behind 
it.  The  circumference  of  the  flaccid  penis  affords  the  best  indication 
as  to  the  size  of  the  urethra,  the  calibre  of  this  canal  increasing  in  pro- 
portion to  the  growth  of  the  penis ;  but  the  ratio  is  only  approximate 
and  is  liable  to  variation. 

It  must  always  be  remembered  that  the  urethra  has  certain  points 
of  normal  constriction,  notably  at  from  one  to  three  inches  from  the 
meatus  and  in  the  vicinity  of  the  pubic  angle,  and  that  it  is  impossible 
to  distinguish  by  means  of  instruments  alone  these  natural  irregu- 
larities from  constrictions  of  equal  calibre  due  to  incipient  stricture. 
However,  when  narrowings  in  any  point  of  the  urethra  are  associated 
with  gleet,  frequent  urination,  dribbling  after  micturition,  and  lumbar 
and  hypogastric  pain,  it  is  safe  to  infer  that  there  is  some  degree  of 
urethral  stricture. 

The  increased  friction  and  resistance  resulting  from  even  a  slight 

14 


210.  GENITO-UEINAET   DISEASES  AND   SYPHILIS. 

fibrous  periurethral  deposit  may  disturb  tlie  equilibrium  which  has 
been  established  and  maintained  between  the  usual  efforts  and  power 
of  the  bladder  as  an  expulsive  organ  and  a  certain  average  of  resist- 
ance which  must  be  overcome  before  it  can  empty  itself.  As  a  result 
the  bladder  becomes  irritable,  and  is  often  rendered  still  more  so  by 
inflammation  of  the  posterior  urethra  incident  to  backward  extension 
of  the  catarrhal  process  usually  active  at  the  seat  of  narrowing.  Thus 
is  caused  one  of  the  most  constant  of  the  stricture  symptoms, — i.e., 
frequent  urination. 

The  imperfect  closure  of  the  tube  occasioned  by  the  inflammatory 
infiltrate,  which  prevents  the  urethral  walls  from  being  pressed  tightly 
to  each  other  by  their  investing  layer  of  involuntary  muscle,  causes 
imperfect  expulsion  of  the  last  drops  of  urine,  and  produces  another 
characteristic  symptom, — dribbling  at  the  end  of  micturition. 

The  retention  and  decomposition  of  these  last  few  drops,  together 
with  the  abnormal  friction  between  the  stream  of  urine  and  the 
urethral  walls  at  the  site  of  narrowing,  cause  a  subacute  inflamma- 
tion of  the  mucous  membrane,  accompanied  by  a  catarrhal  or  muco- 
purulent discharge,  constituting  the  condition  of  gleet. 

Pain  is  developed  in  the  lumbar  and  hypogastric  region  by  reflex 
irritation  transmitted  from  the  area  of  inflammation  and  from  the 
irritated  bladder. 

Where  the  urethral  calibre  is  markedly  diminished,  the  relation 
between  causes  and  effects  is,  in  the  main,  as  just  stated.  As  to  how 
far  the  narrowing  must  go  before  such  symptoms  are  excited,  no  dog- 
matic assertion  can  be  made.  Otis  has  promulgated  a  scale  of  rela- 
tion between  the  calibre  of  the  urethra  and  the  circumference  of  the 
flaccid  penis,  any  departure  from  which  he  regards  as  an  evidence 
of  the  existence  of  stricture.  This  scale  doubtless  represents  accu- 
rately the  distensibility  of  the  male  urethra,  but  it  does  not  represent 
what  can  fairly  be  called  its  normal  calibre,  and  fails  altogether  to 
recognize  the  fact  that  there  are  points  of  physiological  narrowing 
along  the  pendulous  urethra. 

The  variation  in  size  and  dilatabihty  of  the  different  parts  of  the 
urethra  have  long  since  been  clearly  demonstrated  by  Delpet,  Guyon, 
Sappey,  and  many  others. 

Otis,  however,  in  effect  assumes  that  the  urethra  should  be  a  tube 
of  uniform  calibre,  at  least  anterior  to  the  triangular  ligament,  and  the 
instrument  which  he  has  devised, — the  urethrometer, — when  used 
under  the  guidance  of  his  tables,  will  detect  apparent  strictures  in  the 
majority  of  normal  urethrse.  His  teachings  have,  nevertheless,  been 
of  great  value,  since  they  have  demonstrated  the  distensibility  of  the 


STKICTTJRE   OF   THE   UEETHRA.  211 

normal  urethra,  have  clearly  shown  the  full  pathological  value  of  true 
stricture,  however  slight,  and  have  rendered  urethral  surgery  more 
exact. 

For  purposes  of  classification  it  may  be  admitted  that,  exclusive  of 
cases  that  are  best  described  as  examples  of  chronic  urethritis,  there  are 
others  in  which  the  superficial  inflammation  has  largely  disappeared, 
and  in  which  the  periurethral  or  submucous  deposit  has  begun  to 
contract  and  to  diminish  the  lumen  of  the  canal,  the  contraction  still 
allowing  fairly  good-sized  instruments  to  pass  with  ease.  Such  nar- 
rowings  may  be  classed  as  strictures  of  large  calibre.  Strictures  of 
small  calibre  are  those  in  which  the  encroachment  upon  the  canal  is 
more  pronounced. 

A  purely  arbitrary  standard  has  been  established  for  convenience 
in  classifying  organic  strictures  in  accordance  with  the  degree  of  nar- 
rowing.    This  is  expressed  in  the  following  definitions  : 

Strictures  of  large  calibre  are  those  through  which  a  sound  or 
bougie  larger  than  No.  15  (F.)  can  be  passed. 

Strictures  of  sr)iall  calibre  are  those  through  which  instruments 
larger  than  No.  15  (F.)  cannot  be  passed. 

Location  of  Stricture, — In  the  large  majority  of  cases  gonorrhoeal 
stricture  is  situated  in  the  bulbo-membranous  portion  of  the  urethra. 
The  next  most  frequent  seat  is  the  first  two  and  a  half  inches  of  the 
urethra,  and  the  least  frequent  seat  is  the  middle  of  the  spongy 
urethra.  Stricture  of  the  prostatic  region  is  extremely  rare.  The 
occurrence  of  stricture  in  Ihese  regions  is  due  to  the  facts  that  they 
are  exceptionally  vascular,  and,  with  the  exception  of  the  membranous 
urethra,  are  rich  in  glands  and  follicles,  and  that  chronic  urethritis  is 
apt  to  become  localized  at  these  points.  Gravitation  in  both  regions 
favors  chronic  congestion. 

The  differences  of  opinion  in  regard  to  the  localization  of  stricture 
are  due  to  the  different  stand-points  from  which  the  subject  is  regarded. 
Those  who  demand  evidence  of  some  organic  change  before  admitting 
the  existence  of  stricture,  and  who  base  their  views  on  the  exami- 
nations of  specimens  in  museums,  differ  greatly  in  their  conclusions 
from  those  who  depend  upon  the  findings  of  the  urethrometer,  and 
who  believe  in  an  almost  unvarying  relation  between  the  calibre  of 
the  urethra  and  the  size  of  the  penis.  In  three  hundred  and  twenty- 
one  specimens  examined  by  Sir  Henry  Thompson  the  stricture  in 
two  hundred  and  sixteen,  or  sixty-seven  per  cent.,  was  found  in 
the  bulbo-membranous  region ;  in  fifty-four,  or  seventeen  per  cent., 
within  two  and  a  half  inches  of  the  meatus ;  and  in  fifty-one,  or  only 
sixteen  per  cent.,  in  the  intermediate  spongy  portion.     Otis  describes 


212 


GENITO-UKINAEY   DISEASES  AND   SYPHILIS. 


two  hundred  and  fifty-eight  strictures  under  his  care  as  situated,  one 
hundred  and  fifteen,  or  forty-four  and  one-half  per  cent.,  in  the  first 
inch  and  a  quarter  of  the  urethra ;  one  hundred  and  twenty-nine,  or 
fifty  per  cent.,  from  one  and  a  quarter  to  five  and  a  quarter  inches 
from  the  meatus ;  and  only  fourteen,  or  five  and  one-half  per  cent., 
from  five  and  a  half  to  seven  and  a  quarter  inches, — i.e.,  in  the  region 
of  the  bulbo-membranous  urethra.  It  can  scarcely  be  doubted  that 
many  of  these  "  strictures"  were  points  of  physiological  narrowing. 
If  narrowings  at  the  meatus  are  excepted,  gonorrhoeal  strictures 


Fig.  72. 


Traumatic  stricture.  A,  bas-fond  of  bladder;  B,  ecchymosis  of  the  mucous  membrane  of  the 
vesical  neck  :  C,  prostatic  urethra  :  D,  veramontanum,  much  deformed  ;  E,  lacunse ;  F,  position  of 
greatest  narrowing  :  mucous  membrane  transformed  to  a  thin  layer  of  flat  epithelial  cells :  P,  small 
diverticula  in  the  fibrous  tissue  ;  G,  cicatricial  tissue  ;  H,  small  round  cavity  ;  K,  spongy  tissue  com- 
pletely destroyed  ;  K',  mucous  membrane  in  front  of  the  stricture,  thin  and  rugous  ;  L,  spongy  body ; 
M,  anterior  urethra.     (Voillemier.) 


are  usually  single,  though  two,  three,  four,  or  even  more  may  be 
present. 

Traumatic  strictures  are  nearly  always  single,  and  their  situation 
varies  with  the  cause.     They  occur  in  the  mid-spongy  portion  of  the 


STKICTUEE   OF   THE   UEETHRA.  213 

urethra  after  rupture  of  a  chorclee  ;  at  the  root  of  the  penis  when 
caused  by  "false  movements"  in  coition;  in  the  perineo-bulbar  por- 
tions of  the  urethra  when  following  contusions  of  the  perineum  ; 
and  in  the  membranous  portion  after  pelvic  fractures. 

They  are  most  frequently  found  involving  the  bulbous  urethra. 
(Fig.  72.) 

Strictures  following  ulceration  due  to  chancre,  chancroid,  or  the 
lodgement  of  foreign  bodies  are  usually  found  at  or  near  the 
meatus. 

Changes  in  the  Urethra. — The  urethra  behind  a  stricture  under- 
goes certain  progressive  changes.  It  at  first  becomes  deeply  con- 
gested, thinned,  and  dilated.  As  the  stricture  grows  smaller,  altera- 
tions in  the  mucous  membrane  become  more  and  more  marked.  The 
increasing  pressure  causes  a  corresponding  increase  in  the  pouching 
or  dilatation ;  decomposition  of  the  retained  urine  sets  up  superficial 
inflammation,  and  erosion  of  the  mucous  surface  occurs,  with  de- 
nuding of  the  epithelial  layer ;  ulceration  follows,  which,  as  it  pro- 
gresses, allows  the  escape  of  urine  into  the  spongy  tissue.  Sooner  or 
later  this  causes  suppuration.  The  pus,  whether  in  minute  quantity 
or  as  the  contents  of  a  recognizable  abscess,  finds  its  way  towards 
the  skin,  and  after  its  discharge  leaves  urinary  fistulse.  These 
fistulge,  when  first  formed,  have  soft,  yielding  walls,  but  these  grad- 
ually become  dense  and  indurated,  undergoing  the  same  patho- 
logical changes  as  did  the  original  strictured  region.  Even  after  the 
formation  of  a  large  fistula  progressive  contraction  still  takes  place 
at  the  posterior  surface  of  the  urethral  stricture,  since  the  fistu- 
lous opening  cannot  prevent  the  constant  contact  of  urine  with  this 
portion  of  the  narrowing.  As  a  result,  the  urethral  outlet  is  more 
and  more  tightly  sealed,  and  all  the  urine  is  forced  to  pass  by  the 
new  way. 

Gradually  the  walls  of  the  fistula  become  indurated,  its  lumen  is 
narrowed  by  contraction,  and  the  free  passage  of  the  urine  is  again 
obstructed.  Under  such  circumstances  it  is  extremely  rare  to  observe 
any  yielding  in  the  stricture  so  that  water  can  be  voided  perurethram. 
Ordinarily  other  abscesses  develop  in  the  way  already  described,  and 
other  fistulse  are  formed. 

Wassermann  and  Halle  have  shown  that  the  essential  anatomico- 
pathological  characteristic  of  the  lesions  of  gonorrhoeal  stricture  is 
their  multiplicity,  as  opposed  to  the  precise  limitation  and  localiza- 
tion of  traumatic  strictures.  In  all  cases  of  old  gonorrhoeal  strictures 
the  urethra  exhibits  pronounced  lesions  throughout  a  great  part  of 
its  extent.     These  are  most  marked  in  the  region  of  the  bulb.     Th^ 


214  GEFITO-TJKINAEY  DISEASES  AND  SYPHILIS. 

calibre  of  the  urethra  is  lessened  anterior  to  the  stricture ;  beliind  it 
there  is  dilatation. 

Because  it  is  surrounded  by  compressible,  elastic  spongy  tissue, 
the  soft  walls  of  the  normal  urethra  lie  directly  in  contact  with  each 
other,  a  cross-section  showing  it  as  a  slit,  transverse  in  the  spongy 
portion,  vertical  in  the  bulbar.  When  the  periurethral  tissues  are 
thickened  and  rigid,  the  strictured  urethra  becomes  an  open  canal 
with  a  lumen  which  varies  in  shape  according  to  the  position  of  the 
periurethral  infiltration.  In  the  posterior  portion  of  the  bulb  the 
strictured  urethra  exhibits  a  tendency  to  take  the  form  of  a  wide, 
irregular,  transverse  opening,  with  its  lateral  angles  extending  almost 
as  far  as  the  fibrous  envelope  of  the  bulb. 

The  epithelial  lining  of  the  urethra  is  constantly  altered.  Thick- 
ening and  partial  desquamation  represent  the  commonest  lesions. 
These  are  found  in  all  portions  of  the  canal,  even  those  least  altered. 
There  is  constantly  observed  a  tendency  towards  the  transformation  of 
the  cylindrical  epithelium  to  the  stratified  pavement  form.  Commonly 
there  is  a  single  basilar  layer  of  cylindroid  cells  with  the  long  axes 
perpendicular  to  the  derm.  The  middle  layer  is  made  up  of  several 
rows  of  polygonal,  usually  hexagonal,  cells ;  finally,  there  is  a  super- 
ficial layer  continuous  with  the  middle  layer  and  made  up  of  several 
rows  of  flat  cells  with  the  long  diameter  parallel  to  the  derm.  Some- 
times the  flattened  superficial  cell-layer  rests  directly  on  the  basilar 
layer.  All  forms  of  transition  are  observed  in  the  epithelial  cells. 
The  epithelium  may  be  thinned  and  atrophic,  or  there  may  be  pro- 
hferation,  forming  vegetating  masses  which  fill  the  urethral  cahbre. 
Finger  states  that  there  is  a  distinct  relation  between  the  type  of 
epithelial  alteration  and  the  pathological  changes  in  the  subjacent  tis- 
sues. The  distinctly  dermoid  and  corneous  epithelium  (not  observed 
in  the  membranous  or  prostatic  urethra)  is  usually  found  in  the  re- 
gions where  periurethral  sclerosis  is  most  pronounced. 

It  is  important  to  recognize  the  fact  that  these  various  lesions  of 
the  mucous  membrane  are  not  limited,  but  are  almost  universal. 

The  essential  lesion  of  stricture  is  in  the  spongy  body,  x^s  an  ulti- 
mate result  of  inflammatory  infiltration,  fibrous  tissue  is  gradually 
substituted  for  the  elastic,  extensible  vascular  tissue  of  the  spongy 
urethra,  forming  a  compact  inextensible  avascular  mass  showing  a 
tendency  towards  retraction,  atrophy,  and  obliteration.  Usually  the 
narrowing  is  caused  by  a  fibrous  ring,  which  may  be  regularly  dis- 
posed or  unequally  deposited  about  the  urethra.  There  is  no  system 
in  its  distribution.  Sometimes  it  is  the  upper  segment,  sometimes  the 
lower  or  lateral  segments,  that  are  most  profoundly  involved.     At  the 


STRICTURE   OF   THE   URETHRA.  .        215 

strictured  point  one-half  or  two-thirds  of  the  diameter  of  the  spongy- 
body  is  altered  and  obliterated.  This  alteration  often  involves  a  con- 
siderable extent  of  the  canal  beyond  the  point  retracted. 

These  lesions  of  the  spongy  body,  limited  and  irregular  in  cases 
of  chronic  urethritis,  are  in  fibrous  stricture  constant,  deep,  and 
extensive. 

The  arteries  of  the  spongy  body  in  old  cases  constantly  exhibit 
an  endarteritis  and  a  periarteritis,  sometimes  proceeding  to  complete 
obliteration  of  the  vessels.  Behind  the  stricture  the  superficial  inflam- 
matory lesions  are  almost  constant,  and  it  is  here  that  embryonal 
vegetations  form  by  predilection.  The  sclerosed  tissue  surrounding 
the  urethra  is  not  homogeneous,  but  contains  all  the  elements  of  nor- 
mal spongy  tissue.  It  is  the  result  of  a  species  of  interstitial  sclerosis, 
which,  though  completely  modifying  the  appearance  and  the  proper- 
ties of  the  normal  tissue,  does  not  cause  its  total  disappearance. 

In  case  of  traumatic  stricture  the  contrary  is  the  case.  The  spongy 
body  is  entirely  replaced  in  loco  by  an  ordinary  fibrous  cicatrix. 

The  glandular  and  lacunar  lesions  of  stricture  are  constant. 
Adenitis  with  proliferation  and  epithelial  transformation,  glandular 
dilatation,  and  simple  periadenitis  are  nearly  always  found,  especially 
in  the  least  altered  portions  of  the  strictured  urethra.  At  the  seat  of 
stricture  the  glands  have  often  disappeared  or  are  scarcely  recogniza- 
ble. These  glandular  and  lacunar  inflammations  play  an  important 
rdle  in  the  production  of  the  periurethral  lesions,  causing  fibrous 
nodules  to  develop  in  the  spongy  body.  The  irregularities,  the  folds, 
and  the  nodular  masses  observed  in  the  walls  of  strictured  urethrae 
often  originate  in  the  glands  and  their  ducts.  Finally,  the  dilated  and 
suppurating  glands  may  cause  periurethral  abscesses,  false  routes,  or 
fistulous  tracts.  When  these  fistulse  originate  in  the  bulbar  urethra 
it  is  from  the  region  of  one  of  the  lateral  angles  of  the  canal  that  the 
fistulous  tract  passes.  The  sclerosed  bulb  is  not  traversed  directly 
by  this  tract  from  above  downward.  It  winds  laterally  round  the  half 
circumference  of  the  bulb  and  opens  through  the  skin.  Sometimes 
the  bulb  is  entirely  dissected  by  two  fistulous  tracts  placed  symmet- 
rically and  laterally,  uniting  near  a  single  suburethral  pouch.  These 
tracts  are  lined  with  stratified  pavement  epithelium  continuous  with 
the  two  surfaces :  hence  in  closing  them  it  is  necessary  to  extirpate 
the  whole  tract.  In  exploring  these  tracts  it  must  be  borne  in  mind 
that  they  take  a  circuitous  course,  often  entering  the  urethra  by  its 
lateral  wall. 

The  openir^  of  the  urethra  at  the  seat  of  stricture  is  commonly 
near  the  roof  of  the  canal,  since  the  bulk  of  the  fibrous  tissue  is 


21Q       .  GENITO-UEINAEY   DISEASES  AND   SYPHILIS. 

usually  placed  in  the  urethral  floor,  thus  encroaching  upon  the  lumen 
of  the  canal  from  below  upward.  This  opening  may,  however,  be 
eccentric  in  any  other  direction. 

The  consistence  of  strictures  varies  with  their  age  and  with  the 
amount  of  fibrous  and  elastic  tissue  they  contain.  Their  dilatahiUty 
varies  inversely  with  their  consistence,  as  does  their  elasticity. 

Section  of  a  stricture  of  the  annular  or  tortuous  variety  shows  a 
more  or  less  imperfect  ring  of  new  inflammatory  tissue,  Avhose  limits 
taper  down  gradually.  This  tissue  is  hard,  yellowish  white  near  the 
lumen  and  darker  peripherally,  where  reddish  islets  are  seen,  the 
result  of  hemorrhagic  infarcts,  which  form  foci  for  new^  inflammatory 
changes.  Oberlander  has  shown  that  the  inflammatory  process  prac- 
tically begins  in  the  glandular  recesses.  These  are  most  abundant 
on  the  roof  of  the  urethra,  but  the  floor  presents  the  greatest  changes, 
from  the  fact  that  the  gonorrhoeal  process  is  always  more  active 
there. 

Complete  obliteration  of  the  urethra  is  extremely  rare,  and  it  is 
doubtful  if  it  ever  happens  except  in  the  traumatic  forms  of  stricture 
following  extensive  laceration  or  complete  cross-crushing  of  the 
canal.  The  obliteration  in  this  case  is  usually  at  least  half  an  inch 
wide,  with  fistulae  placed  behind  it. 

SYMPTOMS   OF   STRICTURE. 
/  The  phenomena  produced  by  stricture  vary  with  the  degree  and 

'  the  character  of  the  narrowing.  They  are  most  conveniently  clas- 
sified under  the  following  headings:  1,  subjective  symptoms,  those 
recognizable  by  the  patient ;  2,  objective  symptoms,  those  elicited  by 
exploration. 

Subjective  Symptoms. — A.  Urethral  IZtsior^/.— Well-planned  ques- 
tions should  ehcit  the  fact  that  there  has  been  severe  or  recurrent 
urethritis  of  long  duration ;  or  traumatism  to  the  urethra,  perineum, 
or  pelvis  ;  or  a  urethral  chancre  or  chancroid. 

B.  Alterations  in  Micturition.— 1.  Frequency.  This  arises  at  first 
from  the  change  in  relation  between  the  expulsive  efforts  of  the 
bladder  and  the  resistance  offered  by  the  urethra ;  afterwards  from 
extension  of  inflammation  backward  by  contmuity  until  the  vesical 
neck  is  involved  ;  from  cystitis  ;  and  finally  from  atony  of  the  bladder 
with  the  presence  of  residual  urine.  In  these  cases  the  frequency  is 
worse  by  day,  as  in  stone,  not  by  night,  as  in  prostatic  disease. 

2.  Changes  in  the  character  of  the  stream,  which  may  be  double, 
flat,  gimlet-shaped,  or  spray-like,  and  in  tight  strictures  becomes  much 
reduced  in  size,  are  often  of  slight  significance,  as  the  shape  and  size 


STEICTUEE    OF    THE    UEETHEA.  217 

of  the  stream  depend  more  upon  the  shape  and  size  of  the  meatus 
than  upon  any  condition  posterior  to  it.  When  the  meatus  is  of  good 
cahbre  urethral  narrowing  may  remain  unnoticed  for  some  time,  as  a 
compensatory  hypertrophy  of  the  muscular  coat  of  the  bladder  occurs, 
which  overcomes  the  effects  of  the  obstruction. 

3.  Diminution  in  expulsive  power  is  a  late  symptom,  and  is  de- 
veloped only  when  vesical  atony  has  succeeded  to  the  hypertrophy. 

4.  Dribbhng  after  urination  depends  upon  the  retention  of  some 
drops  of  urine  behind  the  stricture.  These  escape  by  gravity  after 
the  act  of  micturition  is  complete.  It  is  usually  an  early  symptom, 
caused  by  irregular  action  of  the  circular  muscular  fibres  of  the 
urethra. 

The  dribbhng  from  the  overflow  of  a  distended  bladder  (inconti- 
nence of  retention)  is  a  very  late  symptom,  and  is  associated  with  a 
high  degree  of  atony  of  the  bladder. 

The  incontinence  of  retention  from  stricture  is  at  first  always 
worse  in  the  daytime,  when  the  patient  is  up  and  about,  while  the  in- 
continence of  retention  due  to  hypertrophy  of  the  prostate  is  worse 
at  night,  when  the  patient  is  lying  down. 

The  mechanism  of  incontinence  from  stricture  is  as  follows.  The 
dilatation  of  the  urethra  behind  the  stricture  having  extended  to  the 
neck  of  the  bladder,  the  urinary  reservoir  becomes  funnel-shaped,  the 
bladder  representing  the  base  and  the  stricture  the  neck.  The  patient 
being  in  the  erect  position,  the  weight  of  the  column  of  urine  comes 
directly  on  the  stricture,  which  permits  it  to  filter  through  drop  by 
drop,  but  when  he  is  rechning  the  bladder  can  fill  up,  and  can  usually 
retain  its  contents  unless  the  changes  in  it  and  in  the  urethra  are  far 
advanced.  In  the  prostatic  patient  it  is  possible  that  the  congestion  of 
the  lumbar  cord  produced  by  the  recumbent  position  makes  urination 
more  frequent  at  night  and  during  the  early  morning  hours. 

5.  Ardor  urinse  is  very  variable,  but  is  not  apt  to  be  marked, 
unless  there  is  a  considerable  degree  of  prostato-cystitis  present. 

6.  Retention  of  urine  may  occur  early  and  suddenly  from  an  acute 
increase  of  the  congestion  of  the  mucous  membrane  in  the  strictured 
region,  or  it  may  be  a  late  symptom  dependent  upon  the  direct  ob- 
struction occasioned  by  the  slowly  contracting  stricture.  In  either 
case  it  is  apt  to  be  precipitated  by  fatigue  or  cold,  or  by  alcoholic  or 
sexual  excess. 

7.  Vesical  tenesmus  is  generally  constant  during  the  entire  act  of 
micturition ;  that  of  prostatic  hypertrophy  is  most  violent  at  the  be- 
ginning and  grows  less  as  the  water  begins  to  flow  ;  that  of  cystitis  is 
most  severe  at  the  '^nd  of  the  act. 


218  GENITO-IJRINAEY   DISEASES  AND   SYPHILIS. 

C.  Urethral  Discharge. — Opinions  vary  as  to  the  constancy  of 
gleet  as  a  symptom,  but  it  is  probable  that  a  large  majority  of  stric- 
tures are  accompanied  by  it.  Most  of  those  patients  who  exhibit  no 
discharge  show  mucous  and  epithelial  shreds  and  pus-cells  in  the 
urine. 

D.  Interferenee  with  Coition. — The  physiological  congestion  of  erec- 
tion necessarily  makes  the  lumen  of  a  tight  stricture  still  smaller, 
thus  causing  retention  of  semen  behind  the  point  of  narrowing. 
This  may  be  extremely  painful  because  of  the  consequent  distention 
of  the  urethra,  often  inflamed  and  hypersensitive.  On  subsidence  of 
erection  the  stricture  may  become  sufficiently  patulous  to  allow  the 
semen  to  drop  slowly  from  the  meatus. 

If  ejaculation  takes  place  at  all  it  is  apt  to  be  premature.  The 
erection  is  often  imperfect  or  subsides  before  the  completion  of  the 
act. 

E.  Constitutional  Symptoms. — These  are  late,  and  depend  upon 
vesical  and  renal  changes,  with  accompanying  alterations  in  the  urine. 
They  are,  therefore,  usually  a  combination  of  uraemic  and  septicaemic 
symptoms.  There  is  a  red  glazed  tongue,  with  anorexia,  dyspepsia, 
constipation,  etc.  The  dryness  of  the  tongue  extends  to  the  walls  of 
the  pharynx,  making  swallowing  painful ;  an  irregular  fever  super- 
venes ;  the  general  strength  fails,  the  face  becomes  pinched  and 
yellow,  the  eyes  sunken,  and  after  rapid  emaciation  and  profound 
prostration  the  patient  dies  comatose. 

Of  the  subjective  symptoms  frequent  urination.^  dribbling^  and  gleet 
are  the  most  characteristic  of  stricture. 

Objective  Symptoms. — Guy  on  divides  the  urethra  into  six  regions  : 

1.  The  navicular  region,  extending  from  the  meatus  to  the  corona. 

2.  The  penile  region,  extending  from  the  corona  to  the  peno-scrotal 
juncture. 

3.  The  scrotal  region,  extending  from  the  anterior  to  the  posterior 
scrotal  wall. 

4.  The  perineo-bulbar  region,  extending  from  the  posterior  scrotal 
wall  to  the  anterior  layer  of  the  triangular  ligament. 

5.  The  membranous  region, 

6.  The  prostatic  region. 

It  must  be  remembered  that  the  superior  urethral  wall  alone  has 
anything  like  a  fixed  curve,  while  the  inferior  wall  is  only  a  broken 
line.  The  inferior  wall  is  extensible,  soft,  and  depressible,  and  is 
subject  to  variations  in  form  and  length :  hence  the  important  point 
for  the  surgeon  to  remember  during  urethral  instrumentation  is  that 
he  should  follow  exactly  the  curve  of  the  superior  wall,  or  by  manipu- 


STKICTUEE   OF   THE   URETHEA.  219 

lations  modify  the  direction  of  the  urethra.  The  part  most  suscep- 
tible of  modification  or  change  in  direction  is  that  extending  from  the 
suspensory  hgament  to  the  entrance  into  the  membranous  division ; 
anatomical  knowledge  and  the  "  touch"  must  be  depended  upon  to 
indicate  the  limit  of  modification  which  the  urethra  will  bear  without 
sustaining  a  lesion.  The  urethra  has  no  lateral  flexions  or  bends,  but 
lies  exactly  in  the  median  line.  Nothing,  however,  is  easier  than  to 
produce  such  deviation  in  the  spongy  urethra,  especially  in  the  bulbar 
portion. 

The  elasticity  and  extensibility  of  the  urethra  reside  for  the  most 
part  in  the  spongy  portion,  as  is  clearly  demonstrated  by  erection,  and 
this  elasticity  belongs  in  the  greatest  degree  to  the  inferior  wall, 
which  permits  of  easy  distention  or  elongation,  while  the  superior 
wall  yields  with  much  less  readiness.  This  difference  increases  with 
age,  and  is  especially  marked  in  the  senile  urethra.  It  is  therefore 
evident  that  since  the  extensibility  of  the  inferior  wall  is  brought  into 
play  by  even  a  moderate  force,  the  surgeon  cannot  count  on  its  re- 
sistance. It  glides  before  an  instrument  and  cannot  serve  to  guide 
it.  It  yields  readily  to  a  mechanical  pressure  testing  its  extensibility  ; 
it  cannot  be  incised  with  any  accuracy  or  precision ;  it  ruptures  when 
surprised  by  distention.  It  does  not  yield  equally  in  all  its  parts,  th^ 
perineo-bulbar  portion  of  the  canal  being  the  most  distensible  part  of 
the  urethra. 

The  superior  wall  is  more  regular  and  constant  in  form  and  direc- 
tion, presents  the  smoother  and  firmer  surface,  is  less  modified  by 
mechanical  pressure,  offers  the  greater  resistance  to  rupture  and  pene- 
tration, is  less  intimately  connected  with  important  structures,  and  is 
the  less  vascular,  of  the  two  walls. 

Fig.  73. 


Cast  of  the  urethra,    a,  navicular  fossa ;  6,  membranous  urethra ;  c,  expansion  of  the  bulb. 

(Letzel.) 

There  are  two  relatively  constricted  points  in  the  urethra,  the 
internal  and  the  external. meatus,  and  three  dilatations,  the  fossa 
navicularis,  the  bulbar  cul-de-sac,  and  the  prostatic  expansion,  all  of 


220 


GENITO-UEINARY   DISEASES   AND   SYPHILIS. 


which  present  numerous  individual  varieties.     These  dilatations  are 
excavated  at  the  expense  of  the  inferior  wall  of  the  canal.     (Fig.  73.) 

Diagnosis. — The  best  instruments  for  the  diagnosis  of  stricture  of 
the  penile  urethra  are  the  so-called  bougies  a  boule  or  the  Otis  ure- 
thrameter.  The  bulbous  bougies  may  be  made  of  metal,  with  slender 
stems,  having  small  expanded  ends,  upon  which  the  number  is 
marked ;  this  represents  in  millimetres  the  circumference  of  the  bulb 
at  the  shoulder.  Better  instruments,  however,  are  the  black  flexible 
bougies  a  boule.  (Fig.  74.)  The  shoulder  of  the  acorn  bulb  should 
join  the  shaft  at  almost  a  right  angle,  and  not  at  an  obtuse  angle. 

Fig.  74. 


Bougie  k  boule. 

The  size  of  the  instrument  selected  for  examination  should  be  de- 
termined approximately  by  noting  the  circumference  of  the  flaccid 
penis  at  the  middle  of  the  spongy  portion.  (Fig.  75.)  The  following^ 
is  an  average  scale  : 

Circumference  of  penis,  3  inches ;  calibre  of  urethra,  26-28  millimetres. 
"       3|-     "  "  .        .      "         28-30 

"       3^-     "  "  "         30-32 

"       3|    "  "  "         32-34 

"      4      "  "  "         34-36 


The  meatus  should  be  cut  if  it  is  too  small  to  permit  the  intro- 
duction of  a  bulbous  bougie  of  the  required  size. 


Fig.  75. 


Gauge  tor  urethral  iustrurnents. 

The  penis,  with  the  dorsum  facing  the  abdominal  wall,  is  held 
just  behind  the  corona  between  the  thumb  and  finger  of  the  left  hand, 
the  foreskin,  if  redundant,  having  been  retracted.  The  bougie,  well 
oiled,  is  then  passed  gently  into  the  bladder.  If  it  is  arrested,  the 
point  on  the  shaft  corresponding  to  the  meatus  is  marked  with  the 
finger  and  the  instrument   is  withdrawn.     The    distance   from  the 


STEICTUEE    OF   THE   UKETHKA.        .  221 

meatus  to  the  bulb  of  the  bougie  is  then  measured,  and  the  region  of 
the  contraction  is  carefully  noted.  If  that  instrument  or  a  smaller  size 
passes  through  to  the  bladder,  it  is  withdrawn  after  a  moment's  delay, 
SLuA  if  during  its  outward  passage  any  contraction  is  found  other  than 
that  at  the  posterior  layer  of  the  triangular  ligament,  it  is  probably 
due  to  stricture,  although  spasm  may  occasionally  give  rise  to  error 
in  diagnosis. 

Spasm  cannot  always  be  recognized  with  certainty.  It  is  generally 
found  at  the  membranous  urethra,  and  occurs  in  many  diseases  of  the 
urinary  tract,  as  in  cystitis,  in  tuberculosis  of  the  bladder  or  posterior 
urethra,  in  phimosis  or  atresia  of  the  meatus ;  it  also  occurs  in  some 
rectal  and  anal  troubles,  and  in  spinal  congestions  and  scleroses,  as 
well  as  in  hysteria  and  neurastlienia. 

Gonorrhoea!  strictures  almost  invariably  give  some  point  of  rough- 
ening or  induration  at  their  favorite  seat, — i.e.,  just  anterior  to  the 
bulb.  In  cases  of  spasm,  when  the  bougie  is  pushed  steadily  onward 
it  will  continue  to  be  held  till  it  passes  through  the  membranous 
urethra,  while  in  stricture  it  is  released  suddenly.  On  withdrawing 
the  bougie  there  should  be  no  resistance  at  this  point  from  spasm, 
while  in  stricture  there  is  an  accentuated  resistance  and  the  same 
sudden  release  on  continuing  to  draw  the  instrument  out.  Sohd  steel 
sounds  if  introduced  gently  nearly  always  pass  without  difficulty  the 
narrowing  due  to  spasm.  Pain  is  usually  greater  in  spasm,  but  this 
is  not  sufficiently  constant  to  be  of  diagnostic  value.  Uncomplicated 
deep  urethral  strictures  may  be  exceedingly  difficult  to  distinguish 
from  narrowing  due  to  spasm  of  the  compressor  urethrae  muscle, 
symptomatic  of  anterior  stricture. 

As  to  the  diagnosis  of  stricture  of  large  calibre,  even  the  bougie  a 
boule  may  be  misleading  if  used  in  the  deep  urethra,  on  account  of 
the  normal  points  of  resistance  to  both  its  introduction  and  its  with- 
drawal which  are  there  found,  while  the  urethrameter  is  similarly 
misleading  in  the  pendulous  urethra,  especially  if  its  revelations  are 
interpreted  according  to  the  unnecessarily  large  standard  of  Otis,  In 
the  latter  region  the  normal  variations  account  satisfactorily  for  the 
large  proportion  of  strictures  found  by  a  few  writers  and  would-be 
teachers  on  this  subject  which  may  charitably  be  put  down  to  self- 
deception.  In  the  deep  urethra  it  has  been  necessary  for  them  to 
account  for  their  frequent  discovery  of  strictures,  even  in  cases  with- 
out the  usual  etiological  factor,  by  attributing  them  to  masturbation, 
sexual  excess,  etc.  It  has  been  demonstrated  that  the  "  deep-seated 
stricture  usually  of  large  calibre  found  at  the  subpubic  curvature  and 
its  vicinity,"  and  described  as  "  an  essential  lesion  of  masturbation" 


222  GENITO-URINAET  DISEASES   AND   SYPHILIS. 

(Gross),  is  in  reality  the  point  of  normal  resistance  to  the  withdrawal 
of  bulbous  bougies  offered  by  the  posterior  layer  of  the  triangular 
ligament. 

The  prostatic  urethra  being  at  once  more  movable  and  more 
dilatable  than  the  membranous  portion,  the  bulb  slips  smoothly  along 
it  until  the  point  is  reached  at  which  the  posterior  layer  of  the  tri- 
angular ligament  closely  embraces  the  posterior  part  of  the  mem- 
branous urethra  and  the  outer  surface  of  the  prostate.  Here,  for 
obvious  reasons,  it  is  arrested,  and  it  is  at  this  moment  that  the  decep- 
tive sensation  which  may  be  considered  indicative  of  the  existence  of 
organic  stricture  is  communicated  to  the  hand. 

A  series  of  observations  and  dissections  upon  the  cadaver  have 
proved  the  soundness  of  this  view,  which  was  originally  purely  theo- 
retical, and,  moreover,  eliminated  the  possibility  of  the  resistance 
being  due  to  a  spasm  of  the  compressor  urethrae  muscle  which  sur- 
rounds the  canal  at  this  point,  arrest  of  the  instrument  occurring  as 
invariably  after  death  as  before.^ 

Having  in  a  number  of  cadavers  carefully  brought  the  bulb  closely 
up  to  the  point  of  resistance,  it  was  held  in  position  while  the  deep 
urethra  was  exposed  by  dissection.  The  shoulder  of  the  bulb  was 
always  foiind  in  the  exact  locality  of  the  deep  layer  of  the  fascia,  the 
edge  of  which  would  often  be  felt  tense  and  cord-like  over  the  upper 
wall  of  the  urethra.  A  division  on  either  side  of  its  attachment  to  the 
ramus  of  the  ischium,  or  to  the  pubis  beneath  the  crura  penis,  would 
then  cause  an  immediate  disappearance  of  the  resistance,  and  the  bulb 
could  be  drawn  outward  smoothly  and  uninterruptedly.  If  the  handle 
of  the  instrument  was  depressed  during  its  withdrawal,  the  edge  of 
the  prostate  became  a  cause  of  obstruction ;  and  it  may  act  thus  to  a 
greater  or  less  extent  in  all  cases. 

The  recognition  of  strictures  of  small  calibre  is  a  matter  of  no 
difficulty.  In  exploring  them  it  is  well  to  use  a  medium-sized  bougie, 
No.  16  or  No.  18  French.  When  this  is  passed  to  the  anterior  surface 
of  the  stricture  the  region  is  noted,  and  its  exact  calibre  determined 
by  using  successively  smaller  instruments.  Multiple  strictures  may 
be  recognized  and  measured  in  the  same  manner.  The  advantage  of 
using  a  rather  large  instrument  at  first  is  that  it  eliminates  the  element 
of  spasm  in  the  membranous  urethra,  which  will  often,  after  a  little 
gentle  pressure,  allow  the  blunt  rounded  point  of  a  medium-sized 
bougie  to  pass,  while  it  would  contract  firmly  and  persistently  before 
the  point  of  a  fine  instrument.    By  using  progressively  smaller  instru- 

1  Philadelphia  Medical  Times,  May  26,  1877. 


STRICTUKE   OF   THE   URETHRA.  223 

ments  also,  the  stricture  can  be  measured  more  accurately  both  in 
calibre  and  in  situation. 

Sometimes,  when  no  bougie  a  boule  will  pass,  a  steel  sound  several 
sizes  larger  will  do  so  with  ease.  The  information  it  conveys  is  not 
so  accurate  as  that  obtained  by  exploration  with  the  acorn  bougie, 
but  is  sufficiently  so  when  the  stricture  is  of  small  calibre. 

In  making  a  diagnosis  between  deep  stricture  and  hypertrophy  of 
the  prostate  the  history  and  age  of  the  patient  are  important  factors. 

In  prostatic  hypertrophy  the  patient  is  apt  to  be  over  fifty  years 
of  age,  and  gives  a  history  of  partial  retention  with  nocturnal  incon- 
tinence of  urine ;  the  urethra  is  lengthened,  so  that  the  shaft  of  a 
catheter  must  be  entered  to  an  unusual  depth  and  the  handle  must 
be  more  than  ordinarily  depressed  before  the  beak  reaches  the  blad- 
der ;  the  obstruction  will  be  found  at  a  distance  of  more  than  six  and 
a  half  inches  from  the  meatus,  and  a  finger  in  the  rectum  will  easily 
make  out  the  enlarged  prostate. 

If  the  points  of  normal  narrowing  of  the  urethra,  at  the  meatus,  the 
middle  of  the  spongy  portion,  and  the  membranous  portion,  are  borne 
in  mind,  together  with  the  resistance  offered  by  the  posterior  layer  of 
the  triangular  ligament  to  the  withdrawal  of  a  bulbous  bougie,  it  is 
hardly  possible  to  mistake  these  narrow  areas  for  stricture. 

The  presence,  location,  and  calibre  of  a  stricture  having  been  de- 
termined, its  dilatability  is  ascertained  by  the  use  of  the  conical  steel 
sound ;  but  it  is  usually  advisable  to  make  this  investigation  at  a 
second  visit. 

RESULTS   OF   STRICTURE. 

Unrelieved  obstruction  of  the  urethral  canal  continued  for  a  pro- 
longed period  produces,  in  addition  to  the  local  conditions  already 
described,  a  series  of  changes  in  the  urinary  tract  posterior  to  the 
lesion.  Under  long-continued  and  increasing  pressure  the  urethra 
gradually  enlarges,  and  the  mucous  membrane  becomes  thinned  and 
pouched,  projecting  in  places  between  the  bands  of  muscular  fibres, 
forming  diverticula  analogous  to  those  seen  in  the  bladder.  Some- 
times, instead  of  permitting  the  gradual  escape  of  urine  through 
minute  openings,  with  the  formation  of  small  abscesses  and  fistulae, 
the  urethra  gives  way  more  largely  at  a  point  behind  the  stricture, 
and  extravasation  of  urine  follows. 

Extravasation  of  Urine. — This  serious  complication  of  stric- 
ture is  usually  preceded  by  the  following  symptoms. 

Symptoms. — After  long  continuance  of  the  ordinary  phenomena 
due  to  stricture  a  tumor  develops   somewhat  suddenly  along  the 


224  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

course  of  the  urethra,  accompanied  by  dysuria  and  frequent  micturi- 
tion or  by  complete  retention. 

If  the  extravasation  is  gradual^  this  tumor  will  fluctuate,  open  ex- 
ternally as  an  abscess,  and  form  a  urethral  fistula. 

If  the  extravasation  is  sudden, — i.e.,  if  the  wall  of  hmiting  inflam- 
matory tissue  thrown  out  at  first  is  suddenly  broken  through  by  the 
efforts  at  micturition,^the  following  symptoms  will  show  the  nature 
of  the  accident.  While  straining  to  evacuate  the  bladder  a  sense  of 
something  having  given  way  is  experienced,  together  with  distinct 
relief  of  bladder  tension,  although  no  urine  escapes  externally.  A 
smarting  or  burning  pain  is  felt  about  the  seat  of  rupture. 

The  local  symptoms  are  those  produced  by  the  retention  of  an 
irritant  and  often  a  poisonous  fluid  within  the  tissues.  The  parts  swell 
and  become  (Edematous,  the  color  of  the  skin  changes  to  a  dusky  red, 
purple,  or  dirty  brown,  emphysema  occurs  from  the  gases  of  decom- 
position, and  spots  of  gangrene  appear.  When  the  urine  is  septic, 
sloughing  may  set  in  by  the  end  of  the  first  day. 

The  general  symptoms  are  those  of  profound  septicaemia,  marked 
by  great  prostration,  irregular  temperature,  a  dry,  glazed  tongue,  a 
running  pulse,  frequent  shallow  respirations,  wandering  dehrium,  and 
finally,  if  the  condition  is  unrelieved,  death  in  coma.  These  develop 
with  greater  intensity  and  rapidity  if  "the  bladder  has  been  infected  with 
putrefactive  microbes  and  the  urine  is  therefore  fetid  and  purulent 
before  extravasation  takes  place. 

The  localizing  symptoms — those  which  indicate  the  point  at  which 
the  urethra  has  given  way — are  based  upon  the  course  taken  by  the 
urine. 

A.  In  case  the  pendulous  urethra  gives  way,  the  result  may  be  as 
follows  : 

1.  When  the  urine  is  not  septic  and  ammoniacal,  and  the  extrava- 
sation is  not  very  rapid,  it  may  remain  strictly  limited,  forming  a  blind 
internal  fistula. 

2.  The  urine  extravasates  into  the  substance  of  the  corpus  spon- 
giosum, passing  forward  in  the  course  of  the  urethra,  and  finally  in- 
volving the  glans  penis  in  the  sloughing  process.  Brodie  states  that 
the  appearance  of  a  black  spot  on  the  glans  penis  after  extravasation 
is  a  fatal  sign,  and  Harrison  concurs  in  this  opinion. 

3.  The  corpus  spongiosum  may  be  protected  by  inflammatory 
exudate,  ulceration  extending  to,  but  not  through,  its  strong  fibrous 
envelope  (Buck's  fascia).  In  this  case  the  urine  may  burrow  forward, 
forming  a  long,  indurated,  fistulous  tract,  opening  externally  behind 
the  glans,  or  on  the  dorsal  surface  near  the  root  of  the  penis. 


STRICTUKE    OF   THE   URETHRA.  225 

4.  Ulceration  involves  the  common  fascia  of  the  penis  at  or  near 
the  point  of  rupture.  In  this  case  the  loose  cellular  subcutaneous 
tissue  of  the  penis  becomes  enormously  oedematous,  the  swelling 
extending  backward  to  the  scrotum.  This  is  the  common  course 
when  rapid  extravasation  takes  place  from  the  pendulous  urethra. 

B.  When  extravasation  occurs  from  any  portion  of  the  urethra 
included  between  the  attachment  of  the  scrotum  and  the  anterior 
layer  of  the  triangular  ligament,  usually  the  bulbar  portion,  the 
course  of  the  extravasated  urine  is  governed  by  the  attachments  of 
the  deep  layer  of  the  superficial  fascia, — Colles's  fascia.  The  urine 
will  first  occupy  the  space  enclosed  by  this  fascia  in  front  and  below 
and  by  the  anterior  layer  of  the  triangular  ligament  behind,  and,  as 
it  cannot  reach  the  ischio-rectal  space  on  account  of  the  attachment 
of  the  fascia  to  the  base  of  the  ligament,  and  cannot  reach  the  thighs 
on  account  of  the  insertion  of  the  fascia  into  the  ischio-pubic  line,  it 
is  directed  into  the  scrotal  tissues,  and  thence  up  between  the  pubic 
spine  and  the  symphysis  until  it  reaches  the  abdominal  wall. 

C.  In  case  the  membranous  urethra  gives  way,  the  extravasated 
urine  is  confined  to  the  region  included  between  the  layers  of  the 
triangular  ligament,  and  gains  access  to  other  parts  only  after  sup- 
puration and  sloughing  have  made  for  it  an  outlet.  The  symptoms 
following  will  then  depend  upon  the  portion  of  the  aponeurotic  wall 
which  first  gives  way.  If  the  anterior  layer  of  the  triangular  liga- 
ment yields,  the  extravasation  will  take  the  course  described  as  char- 
acteristic of  extravasation  from  the  bulbous  urethra ;  if  the  posterior 
layer  yields,  the  course  of  the  urine  will  correspond  with  that  taken 
when  the  prostatic  urethra  is  ruptured. 

D.  If  the  opening  is  situated  behind  the  posterior  layer  of  the  tri- 
angular ligament — in  the  prostatic  urethra — the  urine  may  either 
follow  the  course  of  the  rectum  and  make  its  appearance  in  the  anal 
perineum,  or,  as  it  is  separated  from  the  pelvis  only  by  the  thin  pelvic 
fascia,  it  may  make  its  way  through  the  latter  near  the  pubo-prostatic 
ligament,  where  the  fascia  is  especially  weak,  and  may  spread  rapidly 
through  the  subperitoneal  connective  tissue,  sometimes  forming 
abscesses  in  the  hypogastric  region. 

The  usual  source  of  extravasation  is  from  the  bulbous  and  the 
membranous  urethra,  the  urine  infiltrating  the  perineum  and  scrotum 
and  mounting  upward  to  the  belly-walls.  When  extravasation  occurs 
from  the  membranous  urethra  the  anterior  layer  of  the  triangular 
ligament  nearly  always  gives  way. 

Prognosis. — The  prognosis  of  extravasation  of  urine,  except  in 
those  few  cases  where  inflammatory  reaction  protects  the  surround- 

15 


226  GENITO-URINARY^  DISEASES  AND  SYPHILIS. 

ing  tissues  and  where  local  abscesses  and  fistulEe  are  formed,  is 
always  grave.  When  the  penile  urethra  is  involved  the  skin  usually 
ulcerates,'  thus  allowing  escape  of  urine  before  the  extravasation  has 
become  wide-spread.  Extravasation  into  the  substance  of  the  corpus 
cavernosum  is  fortunately  rare. 

In  extravasation  from  the  bulbous  or  membranous  urethra,  there 
is  httle  prospect  of  spontaneous  relief  being  afforded  by  ulceration : 
hence  prompt  interference  is  necessary  to  prevent  wide-spread  slough- 
ing and  death  from  septic  poisoning. 

Extravasation  from  the  prostatic  urethra,  and  extravasation  from 
the  membranous  urethra,  with  backward  extension  through  the  pos- 
terior layer  of  the  triangular  ligament,  are  the  most  dangerous  forms 
of  this  complication  of  stricture,  since  the  symptoms  are  not  so  char- 
acteristic that  immediate  diagnosis  can  be  made,  and  since  it  is  diffi- 
cult to  drain  the  infected  tissues  thoroughly  when  the  infiltration  is 
fairly  started. 

Treatment. — The  treatment  of  extravasation  of  urine  is  sufficiently 
simple  in  theory.  The  two  indications  are  prevention  of  further  ex- 
travasation, and  thorough  drainage. 

Further  extravasation  is  prevented  by  external  perineal  urethrot- 
omy or  perineal  section.  Usually  an  instrument  can  be  passed,  the 
breach  in  the  urethral  wall  being  upon  the  floor  of  this  channel  and 
not  very  large. 

At  the  same  time  that  the  urethra  is  opened  behind  the  stricture 
the  latter  should  be  thoroughly  divided.  The  entire  infiltrated  area 
is  drained  by  long  multiple  incisions ;  it  is  scarcely  possible  to  overdo 
this  part  of  the  operation.  Two  cuts  are  required  for  the  scrotum, 
two  or  three  for  the  penis,  and,  if  the  case  has  lasted  more  than 
twenty-four  hours,  three  or  four  for  the  abdominal  walls.  As  much 
of  the  extravasated  urine  as  possible  should  be  squeezed  out  through 
these  cuts  by  vigorous  mechanical  pressure,  and  the  tissues  should  be 
washed  with  bichloride  1  to  4000.  The  cuts  should  be  dressed  with 
iodoform,  loosely  packed  with  iodoform  gauze,  and  covered  with  hot 
antiseptic  fomentations,  changed  every  two  hours  (twenty  layers  of 
gauze  wrung  out  in  bichloride  1  to  4000  and  covered  with  oiled  silk). 

When  the  prostatic  urethra  gives  way,  external  perineal  urethrot- 
omy and  drainage  may  not  suffice.  If  the  infiltration  has  been  ex- 
tensive, the  parietal  incision  for  suprapubic  cystotomy  will  also  be 
required,  the  prevesical  space  being  irrigated  and  drained.  By  digital 
examination  through  the  rectum,  boggy  or  indurated  areas  can  be 
detected  about  the  base  of  the  bladder,  and  must  be  opened  and 
drained  through  the  perineum. 


STEIOTUEE   OF   THE   UEETHKA.  227 

Bladder. — The  bladder  becomes  affected  as  the  stricture  narrows. 
Occasionahy,  when  the  obstruction  occurs  suddenly,  the  walls  are  at 
once  thinned  and  atrophied  by  overdistention.  As  a  rule,  however,  a 
compensatory  hypertropliy  takes  place  first,  the  muscles  become  thick 
and  rigid,  the  capacity  of  the  viscus  diminishes,  and  the  muscular 
fibres  stand  out  in  bars  or  ridges,  having  between  them  lozenge- 
shaped  spaces  where  the  walls  are  greatly  thinned.  During  the  fre- 
quent and  violent  contractions  of  the  viscus  the  mucous  membrane  is 
driven  outward  between  these  muscular  partitions,  and  the  bladder 
finally  becomes  pouched  at  a  number  of  places. 

Usually  there  is  also  a  severe  cystitis  developed  by  infection 
through  the  urethra  and  adding  greatly  to  the  severity  of  the 
symptoms.  Exceptionally  the  saccuh  rupture,  causing  collapse  and 
death. 

Ureters. — The  ureters  become  dilated  partly  from  the  actual 
backward  pressure  of  the  column  of  urine  incident  to  distention  of 
the  bladder,  and  partly  from  the  frequent  compression  of  their  vesi- 
cal ends  during  the  oft-repeated  acts  of  urination.  Their  oblique 
course  through  the  walls  of  the  bladder  renders  this  compression 
very  effective,  and  hydronephrosis  is  developed,  causing  mechanical 
obstruction  to  the  secretion  of  urine. 

Kidneys.— Sooner  or  later  microbic  infection  takes  place,  and  the 
renal  alterations  due  to  suppurative  inflammation  follow.  A  pyelo- 
nephritis first  develops,  and  then  foci  of  suppuration  are  formed  at 
different  points  through  the  cortex  and  beneath  the  capsule,  until 
finally  the  kidney  is  converted  into  a  large  abscess-cavity,  or  into  a 
series  of  pus-containing  sacs,  held  together  by  the  capsule  and  in- 
flammatory lymph,  and  showing  no  trace  of  the  secreting  structure. 
This  condition  is  called  surgical  kidney. 

Among  the  possible  results  of  stricture  may  be  mentioned  vesical 
calculus,  impotence,  sterility,  recto-vesical  fistula,  and  very  rarely 
spinal  sclerosis  or  some  of  the  forms  of  cerebral  disease. 

Prognosis  of  Stricture. — The  prognosis  as  to  life  depends,  of  course, 
on  the  stage  which  has  been  reached  and  upon  the  estimate  which  may 
be  formed  of  the  secondary  organic  changes  that  have  already  taken 
place.  Relief  of  the  obstruction,  drainage  and  antisepsis  of  the  blad- 
der, milk  diet,  renal  antisepsis,  etc.,  often  work  astonishing  changes  in 
apparently  desperate  cases. 

Fenwick  has  forcibly  called  attention  to  the  fact  that  in  the  prac- 
tical treatment  of  stricture  we  too  often  concern  ourselves  merely 
with  the  mechanical  removal  of  the  obstruction,  and  do  not  pause  to 
ascertain  to  what  extent  the  secreting  structure  of  the  kidney  has 


228  GENITO-UEINAKY   DISEASES   AND  SYPHILIS. 

been  weakened  or  rendered  susceptible  to  the   invasion  of  inflam- 
mation from  continuous  surfaces. 

Fen  wick  emphasizes  the  fact  that  in  the  obstruction  offered  to  the 
overflow  of  urine  by  unreHeved  stricture  three  muscular  systems — 
the  vesical,  the  ureteric,  and  the  cardiac — become  successively  affected 
with  hypertrophy.  He  finds  that  residual  urine  exists  in  varying  pro- 
portions in  ninety-three  per  cent,  of  cases  of  stricture,  and  reaches 
the  following  conclusions : 

1.  In  estimating  the  health  of  the  kidneys  from  the  indications  af- 
forded us  by  the  examination  of  the  residual  urine,  the  amount  of  press- 
ure which  the  kidneys  have  been  working  against  must  be  remembered. 
This  is  to  be  measured  by  the  quantity  of  residual  urine.  It  may  be 
safely  assumed  that  five  ounces  of  residual  urine,  which  is  probably  near 
the  average  of  unreleased  narrow  strictures,  would  indicate  sufficient 
damage  to  cause  anxiety  as  to  the  effects  of  any  intercurrent  inflamma- 
tion or  disease,  while  an  amount  over  ten  ounces  would  make  us  cau- 
tious in  operating  for  stricture  by  internal  urethrotomy,  and  in  giving 
anything  but  a  grave  prognosis  of  the  ultimate  effects  of  the  constriction, 

2.  The  behavior  of  the  muscles  in  their  progress  towards  recovery 
will  teach  us  much  as  regards  the  future  course  of  the  case.  A  dis- 
position to  relapse  or  sluggishness  in  recuperation  would  cause  us  to 
look  forward  with  apprehension  to  that  period  of  life  when  fatty  and 
senile  changes  will  step  in  to  aggravate  greatly  the  weakness  of  an 
organ  upon  the  condition  of  which  comfort  and  health  in  old  age  are 
mainly  dependent. 

3.  We  are  amply  justified,  when  the  initial  amount  of  residual  urine 

is  under  five  ounces,  and  when  recovery  of  the  normal  calibre  is  prompt, 

in  giving  a  good  prognosis,  provided  the  full  calibre  of  the  urethra  is 

maintained. 

TREATMENT    OF   ORGANIC    STRICTURE. 

The  various  methods  employed  in  the  treatment  of  stricture  may 
be  divided  into :  1,  dilatation  :  a,  gradual ;  6,  continuous ;  2,  inter- 
nal   UTETHROTOMY  ;    3,    EXTERNAL    URETHROT- 

^'^'-  ^^-  OMY  ;      4,    COMBINED     INTERNAL   AND     EXTERNAL 

URETHROTOMY  ;    5,    PERINEAL   SECTION  ;    6,    MIS- 

^ cELLANEOUs    METHODS,   including    divulsion, 

*^^  rapid  dilatation,  electrolysis,  excision,  ureth- 
.  rectomy,  etc. 
Filiform  bougies.  Gradual    Dilatation.— The     instru- 
ments for  the  gradual  dilatation  of  stricture 
consist  of  a  set  of  whalebone  filiform  bougies  with  straight,  angular, 
and  spiral  ends  (Fig.  76) ;  a  set  of  tunnelled  catheters,  ranging  from 


STRICTURE   OF   THE   URETHRA..  229 

No.  8  or  10  to  No.  18  French  (Fig.  77) ;  a  set  of  Thompson's  conical 
steel  sounds,  running  from  No.  12  to  No.  36  French  (Fig.  78);  and 

Fig.  77. 


Tunnelled  catheter.    Enlargement  of  tip  showing  position  of  tunnel. 

some  flexible  bougies  of  different  sizes, — acorn,  conical,  and  bulbous 
or  olive-tipped.     The  flexible  bougies  should  be  so  constructed  that 

Fig.  78. 


steel  sound. 


the  portion  just  behind  the  tip  is  sufficiently  yielding  to  allow  the 
latter  to  follow  the  sinuosities  of  a  tortuous  stricture.  Slight  pressure 
upon  the  end  of  such  a  bougie  should  cause  flexion  of  the  neck. 
The  Enghsh  bougies  are  objectionable  because  they  are  not  made 
sufficiently  flexible  near  the  tip.  The  steel  instruments  should  be 
absolutely  free  from  rust  or  any  surface  roughness.  The  flexible 
bougies  should  be  smooth,  strong,  and  without  cracks. 

In  selecting  filiform  bougies  great  care  should  be  exercised,  since 
many  of  these  instruments  are  improperly  constructed  or  have  been 
kept  so  long  that  they  are  brittle  and  dangerous.  The  end  of  the  in- 
strument should  be  bulbous  and  the  tapering  neck  should  be  flexible 
yet  tough.  The  surgeon  should  be  able  with  his  thumb-nail  to  angle 
the  last  half  inch  of  the  instrument  without  breaking  any  of  its  fibres,  and 
whilst  flexible  its  shaft  should  be  sufficiently  stiff  to  allow  of  a  push 
on  the  handle  being  transmitted  to  its  tip.  Though  the  conical  steel 
sounds  are  commonly  used  in  the  curative  treatment  of  structures  of 
large  calibre,  the  woven  bougies  with  lead  core  bulbous  tip  B.ndjlexible 
neek  behind  this  tip  are  at  times  invaluable.  This  is  particularly  the 
case  when  the  opening  of  the  structure  is  eccentric  and  is  complicated 
by  an  unusual  degree  of  spasm  of  the  compressor  urethral  muscle.  The 
flexible  instrument  under  such  circumstances  allows  of  easy  penetration 
with  the  least  possible  amount  of  traumatism,  and  can  often  be  passed 


230  GENITO-UEINAEY    DISEASES   AND   SYPHILIS. 

without  difficulty  wtien  the  introduction  of  steel  sounds  is  impossible. 
These  instruments  should  be  carefully  tested  on  purchase  to  see  that 
extreme  flexibility  is  present  at  the  portion  where  it  is  most  needed, — 
that  is,  in  the  narrowed  portion  just  behind  the  bulbous  extremity. 

Cleansing  of  Instrumenfs. — The  principles  of  urethral  antisepsis  must 
be  rigorously  applied  in  the  care  of  these  instruments.    (See  page  279.) 

Cleansing  of  the  Urethra. — In  cases  requiring  tlie  use  of  sounds  the 
meatus  and  its  immediate  environment,  together  with  the  urethra, 
are  often  swarming  with  pyogenic  organisms,  which,  gaining  entrance 
to  the  system  through  slight  cracks  or  through  abrasions  incident  to 
the  passage  of  the  instrument,  may  occasion  violent  inflammation, 
with  its  sometimes  serious  local  and  general  sequelae.  To  lessen  the 
danger  as  far  as  possible,  the  glans  and  foreskin  should  be  thoroughly 
cleansed  by  means  of  pledgets  of  cotton  wet  with  bichloride  of  mer- 
cury 1  to  1000.  In  women  it  is  particularly  important  thoroughly  to 
cleanse  the  region  about  the  urinary  meatus  before  passing  an  instru- 
ment into  the  bladder :  hence  catheterization  by  touch  alone  is  to  be 
discouraged. 

The  urethra  should  be  flushed  of  purulent  contents  by  directing 
the  patient  while  micturating  forcibly  to  stop  the  stream  abruptly  by 
sudden  closure  of  the  meatus  with  the  finger.  When  there  is  free 
muco-purulent  discharge,  the  whole  urethra  should  receive  an  anti- 
septic irrigation,  either  by  means  of  injections  thrown  in  by  an  ordinary 
syringe,  by  a  small  soft  rubber  catheter  attached  to  a  fountain  syringe 
passed  beyond  the  stricture  and  very  slowly  withdrawn  while  the 
antiseptic  fluid  is  flowing,  or  by  the  irrigating  bag  and  short  urethral 
nozzle. 

When  the  bladder  has  been  infected,  if  the  urethra  is  permeable, 
it  is  best  to  precede  the  systematic  treatment  of  stricture  by  irrigation 
with  some  antiseptic  solution,  as  sublimate  (from  1  to  20,000  to  1  to 
10,000),  potassium  permanganate  (1  to  5000  to  1  to  1000),  boric  acid 
(fifteen  grains  to  the  ounce  of  boiled  water),  protargol  (1  to  2000  to 
1  to  200),  or  silver  nitrate  (from  1  to  5000  to  1  to  500).  At  the  same 
time,  when  the  stomach  permits,  it  is  important  to  administer  anti- 
septic drugs,  such  as  salol  and  boric  acid,  in  from  five-  to  ten-grain 
doses,  from  four  to  six  times  daily. 

These  preliminaries  having  been  attended  to,  the  entire  urethra 
having  been  ansesthetized  by  instillations  (see  page  159)  of  a  four  per 
cent,  eucaine  solution,  and  the  stricture  having  been  located,  a  conical 
steel  sound,  two  sizes  larger  than  the  bulb  which  has  passed  the  stric- 
ture, is-warmed  and  sterilized  by  flaming  it  with  alcohol,  lubricated, 
and  carefully  introduced  through  the  stricture. 


STRICTUEE    OF    THE   URETHRA. 


231 


The  fixed  curve  of  the  urethra — i.e.,  the  curve  assumed  by  the 
majority  of  adult  urethras  in  a  condition  of  rest — is  measured  from 
just  in  front  of  the  triangular  ligament  to  the  neck  of  the  bladder. 
(Fig.  79.)    It  is  theoretically  considered  as  that  part  of  a  circle  of  three 


Fig.  79. 


Tip  of  catheter  just  entering  the  fixed  curve  of  the  urethra.  (Antal.)  A,  rectum  ;  B,  bladder; 
C,  symphysis  pubis  ;  B,  seminal  vesicle ;  E,  bulb ;  F,  tip  of  instrument  entering  the  fixed  curve  of 
the  urethra  ;  G,  prostate. 

and  one-quarter  inches'  diameter  which  is  subtended  by  a  chord  two 
and  three-quarters  inches  long.  (Fig.  80.)  Practically  this  curve  varies 
greatly  from  this  standard.  Indeed,  it  is  not  a  continuous  curve. 
Depressing  the  urethra  by  means  of  a  fmger  placed  on  either  side  of 
the  root  of  the  penis  somewhat  straightens  this  curve.  It  is  always 
lengthened  by  hypertrophy  of  the  prostate  or  a  much  distended  blad- 
der. It  may  be  temporarily  obliterated  by  passing  a  straight  instru- 
ment into  the  bladder.     (Fig.  81.) 


232 


GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 


Passing  the  Sound. — For  the  passage  of  a  properly  made  steel 
sound  or  silver  catheter,  the  curve  of  which  corresponds  with  that 
given  above,  the  patient  should  be  placed  in  the  recumbent  position, 


Fig.  80. 


Fixed  urethral  curve. 


with  the   head  and  shoulders   slightly  elevated,  the  knees  a  little 
separated,  and  the  muscles  relaxed.     The  surgeon,  if  right-handed, 


Fig.  si. 


Fixed  curve  of  the  urethra  obliterated  by  the  passage  of  a  straight  instrument.    (Antal.)    A,  rectum , 
B,  bladder ;  C,  symphysis  pubis ;  D,  scrotum ;  E,  prostate ;  F,  tip  of  catheter  in  bladder. 

stands  at  the  left  side  of  the  patient.  The  sound  or  catheter,  having 
been  previously  sterilized,  warmed,  and  lubricated,  is  taken  in  the 
right  hand,  and,  the  foreskin  having  been   retracted,  the   penis  is 


STRICTURE    OF    THE    URETHRA. 


233 


held  between  the  middle  and  ring  fingers  of  the  left  hand.  The 
organ  is  gently  put  on  the  stretch,  care  being  taken  to  keep  the  dor- 
sum towards  the  abdominal  wall,  so  as  to  avoid  making  twists  in 
the  urethra,  the  lips  of  the  meatus  are  separated  by  the  thumb  and 
finger  of  the  left  hand,  and  the  tip  of  the  instrument  is  passed  into 
the  urethra.  At  this  time  the  shaft  of  the  sound  or  catheter  should 
be  parallel  to  the  line  of  the  groin.     (Fig.  82.)     This  is.  important 

Fig.  82. 


Passing  the  sound.    The  .shaft  is  parallel  with  Poupart's  ligament ;  the  tip  has  entered  the  urethra. 


chiefly  in  persons  with  large,  protuberant  bellies,  in  whom,  if  this 
rule  is  not  followed,  the  tip  of  the  instrument  will  be  made  to  catch 
against  the  anterior  layer  of  the  triangular  ligament,  owing  to  the  ele- 
vation of  the  handle  necessitated  by  the  prominent  abdomen.  In 
any  event  the  handle  of  the  instrument  must  be  kept  low  until  the 
tip  is  about  to  enter  the  membranous  urethra.  Having  engaged  the 
point  of  the  sound,  the  penis  is  now  drawn  up  with  the  left  hand, 
while  the  instrument  is  graduaUy  pushed  onward,  until  three  or  four 
inches  of  the  shaft  have  disappeared,  when  the  handle  is  swept  inward 
to  the  median  line,  the  shaft  being  kept  parallel  to  the  anterior  plane 
of  the  body  and  nearly  touching  the  abdomen.  (Fig.  83.)  The  shaft 
of  the  instrument  is  now  pushed  downward  towards  the  feet,  and  as 
soon  as  this  motion  is  arrested  the  fingers  of.  the  left  hand  are  removed 
from  their  hold  on  the  penis  and  shifted  to  the  perineum,  v/here  the 
curve  of  the  instrument  is  felt  behind  the  scrotum.     (Fig.  84.)     The 


234 


GENITO-URINAEY   DISEASES   AND   SYPHILIS. 


handle  is  then,  and  not  till  then,  raised  from  the  abdominal  wall  and 
swept  gently  over  in  the  median  line,  while  the  left  hand  acts  as  a 


Fig.  83. 


Passing  the  sound.    The  shaft  is  carried  inward  to  the  middle  line  of  the  body. 
Fig.  84. 


Passiuy  the  sniinil.    The  shaft  of  the  instrument  swept  upward  ;  the  fingers  of  the  left  hand  placed 

against  the  perineum. 

falcrmn  over  which  the  instrument  glides.    After  the  shaft  has  passed 
the  perpendicular,  tlie  liandle  is  taken  in  the  left  hand,  and  the  index 


STKICTURE    OF    THE    URETHRA. 


235 


and  middle  fingers  of  the  right  hand  are  placed  one  on  either  side  of 
the  root  of  the  penis,  making  downward  pressure,  while  the  left  hand 


Fig.  85. 


Pafssing  the  sound.    The  handle  taken  in  the  left  hand,  the  fingers  of  the  right  hand  making  down- 
ward pressure  at  the  root  of  the  penis. 

Fig.  86. 


I'Dsitiidi  o!'  .^(Jiiiid,  shouiii'j;  tli.it  ii-  tip  has  entered  the  bladder. 


depresses  the  handle  between  the  legs,  carrying  the  point  of  the  in- 
strument through  the  membranous  and  the  prostatic  urethra  into  the 


236  GEXITO-URIXARY   DISEASES   AND    SYPHILIS. 

bladder.  (Fig.  85.)  The  entrance  into  this  organ  is  recognized  by 
the  free  motion  of  the  tip  of  the  sound  Avhen  the  handle  is  rotated, 
and  by  the  fact  that  the  instrument  remains  exactly  in  the  median 
line  and  points  away  from  the  pubes  when  the  hold  upon  it  is  re- 
laxed. (Fig.  86.)  The  whole  manoeuvre  must  be  effected  with  gentle- 
ness ;  no  force  is  necessary. 

If  there  is  a  spasm  of  the  circular  muscular  fibres  of  the  urethra 
at  any  point,  or  of  the  compressor  urethree  at  the  bulbo-membranous 
juncture,  gentle  steady  pressure  for  a  minute  or  two  usually  will  be 
followed  by  relaxation. 

If  the  handle  is  lifted  too  soon  from  its  proximity  to  the  abdominal 
wall,  the  tip  of  the  instrument  catches  in  the  subpubic  ligament  above 
the  urethral  orifice  ;  if  the  handle  is  not  raised  soon  enough,  or  if  the 
fingers  on  the  perineum  do  not  give  the  curve  of  the  instrument  the 
gentle  upward  pressure  that  it  needs,  the  tip  buries  itself  in  the  loose 
and  movable  floor  of  the  bulbous  urethra  below  the  orifice  of  the 
membranous  portion  of  the  canal.  (See  Fig,  73.)  In  either  case  the 
curve  of  the  sound  protrudes  unnaturally  in  the  perineum.  The 
withdrawal  of  the  instrument  for  an  inch  or  two  and  its  reintroduc- 
tion,  raising  or  lowering  the  tip  as  may  be  required,  will  suffice  to 
overcome  the  obstacle. 

If  the  instrument  is  used  with  ordinary  care  and  gentleness  and 
has  been  properly  sterilized,  and  if  it  is  immediately  followed  by  a  total 
antiseptic  irrigation  (protargol  1  to  2000  to  1  to  200 j,  the  production 
of  prostatitis,  epididymitis,  or  urethral  fever  will  follow  with  extreme 
rarity.  In  a  majority  of  cases  these  compHcations  are  due  to  the  use 
of  force  in  the  introduction  of  the  bougie,  when  the  instrument  prac- 
tically becomes  a  divulsor,  or  to  a  slovenly  chsregard  of  antisepsis, 
either  the  instruments  not  having  been  sterilized  or  the  urethra  not 
having  received  antiseptic  irrigation  before  m.anipulation. 

Sometimes  a  few  drops  of  blood  follow  the  withdrawal  of  the  in- 
strument, the  next  act  of  urination  may  be  slightly  painful,  and  often 
the  gleety  discharge  will  increase  for  a  day  or  two. 

The  method  of  treating  stricture  by  gradual  dilatation  consists  in 
the  passage  of  sounds  of  increasing  gauge  at  intervals  of  from  three  to 
five  days,  till  the  stricture  readily  admits  an  instrument  corresponding 
in  size  to  the  normal  calibre  of  the  urethra. 

Each  sounding  is  followed  by  a  slight  and  transitory  hyperaemia 
of  the  region  about  the  stricture,  and  during  this  time,  particularly  in 
recent  cases,  an  appreciable  softening  and  absorption  of  the  stricture 
tissue  may  occur.  This  period  lasts  from  three  to  four  days,  and  not 
until  it  subsides  is  the  passage  of  an  instrument  to  be  repeated. 


STRICTURE    OP    THE    URETHRA.  237 

Ordinarily  an  advance  of  one  or  two  numbers  of  the  French  scale 
may  be  made  each  time,  but  occasionally  the  same  instrument  must 
be  introduced  at  several  sittings  before  it  can  be  exchanged  for  a 
larger  one.  This  is  determined  by  the  degree  of  resistance  experi- 
enced during  its  introduction,  the  pain  which  it  excites  at  the  time  and 
afterwards,  and  the  presence  or  absence  of  bleeding.  Personal  expe- 
rience soon  becomes  the  best  guide  as  to  the  degree  to  which  dilatation 
may  be  carried  at  any  one  sitting,  though  the  feelings  of  the  patient 
should  always  be  consulted.  When  the  full  size  has  been  reached 
(vide  table,  page  220)  the  symptoms  will  usually  disappear,  and  after 
this  it  is  only  necessary  to  carry  on  the  dilatation  at  increasingly 
longer  intervals  to  maintain  the  calibre  of  the  urethra.  If  the  patient 
is  of  average  intelligence,  it  is  eAsy  to  teach  him  to  pass  an  instrument 
on  himself  without  the  least  discomfort  or  inconvenience. 

A  certain  proportion  of  cases  under  this  plan  of  treatment  will 
get  entirely  well,  so  that  years  afterwards  no  trace  of  stricture  can  be 
chscovered.  Others,  if  the  intervals  between  the  introduction  of  the 
sound  are  too  long,  will  have  a  shght  recontraction,  evidenced  possi- 
bly by  a  recurrent  gleet,  and  the  treatment  will  have  to  be  repeated. 

The  introduction  of  a  sound  into  any  stricture  which  it  fills  with- 
out causing  laceration  is  accompanied  by  certain  phenomena.  There 
is  felt,  at  the  end  of  a  minute  or  two,  a  difficulty  in  withdrawing  the 
instrument.  Soon  the  spasm  disappears,  and  movement  of  the  sound 
becomes  easy  again.  Some  hours  later  a  muco-purulent  discharge  is 
established  in  the  canal,  and  in  a  few  days  the  stricture  allows  the 
passage  of  a  larger  sound.  The  permanent  enlargement  obtained  is 
principally  due  to  absorption  incident  to  the  congestion  excited  in 
the  stricture  by  the  presence  of  the  foreign  body,  and  not  to  the 
mechanical  dilatation  and  pressure  of  the  sound.  Therefore,  whert 
it  is  desired  to  make  this  inflammation  a  little  more  severe,  it  is  well 
to  leave  the  sound  in  situ  for  five  or  ten  minutes.  The  point  may  be 
withdrawn  a  little  during  this  time,  to  avoid  irritation  of  the  prostato- 
vesical  region.  The  effect  of  sounds  of  gradually  increasing  size  is 
to  stimulate  the  work  of  absorption  and  to  cause  the  contractile  ele- 
ments to  atrophy  and  the  urethra  to  resume  approximately  its  normal 
character. 

These  remarks  apply  to  all  strictures,  except  those  compHcated 
with  abscesses,  fistulse,  urinary  extravasation,  etc.,  or  those  in  which 
there  is  marked  resiliency,  or  where  instrumentation  is  followed  by 
rigors  and  urethral  fever. 

All  surgeons  are  agreed  that  uncomplicated  strictures  of  large  calibre 
should  he  treated  by  gradual  dilatation  ivhen  they  are  at  or  behind  the 


238  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

bulbo-membranous  juncture.  The  treatment  is,  however,  rejected  by 
-some  surgeons  in  favor  of  the  cutting  operation  when  such  strictures 
of  the  pendulous  urethra  are  encountered. 

A  review  of  a  large  number  of  reported  cases  of  internal  urethrot- 
omy, and  familiarity  with  a  considerable  number  even  less  favorable 
and  not  reported,  lead  us  to  beheve  that  these  figures  rather  under- 
estimate the  mortality,  and  that  the  practitioner  who  decides  to  cut  a 
stricture  anterior  to  the  bulbo-membranous  juncture  must  do  so  with 
the  full  knowledge  that  there  are  at  the  very  least  two  chances  'n 
the  hundred  of  losing  his  patient.  There  should  certainly  be  definite 
and  well-grounded  reasons  for  accepting  this  risk,  and  the  operation 
which  involves  it  should  ,show  results  unmistakably  superior  to  those 
of  gradual  dilatation, — a  procedure  with  practically  no  mortality. 

It  is  not  in  accord  with  other  pathological  observations  to  suppose 
that  the  mere  division  of  a  dense  and  old  contractile  band  of  fibrous 
tissue  will  result  in  its  absorption,  and  it  is  highly  probable  that  the 
majority  of  the  true  strictures  of  the  spongy  urethra  which  are  cured 
by  internal  urethrotomy  are  those  in  which  the  division  of  the  stric- 
ture is  supplemented  by  the  use  for  some  time  of  full-sized  bougies. 
The  relief  of  tension  afforded  by  the  section  of  the  stricture  gives  full 
play  to  the  so-called  "  inflammatory  atrophic  dilatation,"  and  in  a 
certain  proportion  of  cases  either  retrograde  metamorphosis  and 
absorption  take  place,  or  there  are  at  least  a  thinning  and  weakening 
of  the  fibrous  band,  which  result  in  its  practical  disappearance  as  a 
cause  of  obstruction. 

It  is  also  probable,  on  both  chnical  and  pathological  grounds,  that 
the  great  majority  of  so-called  strictures  of  the  pendulous  urethra 
which  are  cut  by  the  extremists  in  urethrotomy  are  points  of  physio- 
logical narrowing,  and  that  the  so-called  "  cures"  are  merely  illustra- 
tions of  the  fact  that  by  a  hnear  incision  into  its  long  axis  we  can  put 
in  the  normal  urethra  a  longitudinal  splice  of  fairly  healthy  tissue 
which  has  little  tendency  to  contract  afterwards,  and  can  thus  more 
or  less  permanently  enlarge  the  urethral  calibre. 

It  is  difficult  to  see,  however,  why  such  a  sphce  should  prevent 
the  steady  contraction  of  a  mass  of  old  cicatricial  tissue,  such  as  occu- 
pies the  wall  of  the  canal  and  the  periurethral  space  in  strictures  of 
some  standing. 

Strictures  of  Small  Calibre. — The  diagnosis  of  stricture  of  small 
calibre  (less  than  15  French),  situated  at  or  deeper  than  the  bulbo- 
membranous  juncture,  is  made  either  with  the  bulbous  bougie,  if  that 
can  be  passed  through,  or  by  the  introduction  of  a  sound  down  to  the 
anterior  face  of  the  contraction.     Such  strictures  are  usually  accom- 


STRICTUKE   OF    THE    URETHRA.  239 

panied  by  gleet  and  marked  vesical  symptoms,  increasing  in  severity 
vvrith  the  tightness  of  the  contraction. 

The  choice  of  treatment  lies  between  dilatation  and  some  form  of 
urethrotomy.  Divulsion  is  so  clumsy,  so  uncertain,  and  so  dangerous 
as  to  have  almost  no  advocates  to-day. 

In  beginning  the  treatment  of  a  stricture  of  small  calibre  it  is  best 
to  pass  through  it  a  steel  sound,  provided  its  introduction  requires 
no  force.  It  is  not  safe  to  use  a  sound  smaller'  than  No.  8  or  No.  10 
of  the  French  scale,  as  even  in  the  most  skilful  and  experienced 
hands  there  is  an  unavoidable  danger  of  lacerating  the  inflamed  and 
degenerated  mucous  membrane  around  the  strictured  region.  It  is 
in  the  exploration  of  deep  stricture  of  small  calibre  that  "  false  pas- 
sages" are  usually  made,  and  almost  always  with  small  metallic  in- 
struments, either  sounds  or  catheters.  The  mucous  membrane  in 
front  of  a  tight  stricture  is  generally  inflamed  and  softened,  and  if 
fistulas  have  formed  behind  the  stricture,  diverting  the  course  of  the 
urine,  the  anterior  portion  of  the  strictured  region  undergoes  atrophy, 
as  it  is  no  longer  subject  to  constant  irritation,  and  a  thin-walled  dila- 
tation is  frequently  found  there,  which  offers  but  little  resistance  to 
the  point  of  an  instrument. 

When  a  false  jjassage  is  made,  the  sensation  conveyed  to  the  hand 
differs  markedly  from  that  attending  a  successful  catheterization. 
The  point  of  the  instrument  is  not  in  the  median  line,  and  is  held 
with  unusual  firmness.  There  is  free  bleeding  almost  immediately ; 
the  finger  in  the  rectum  will  detect  the  deflection  of  the  instrument, 
and  the  absence  of  the  normal  thickness  of  urethral  and  prostatic  tissue 
beneath  its  curve.  If  there  is  no  retention  of  urine,  the  immediate 
treatment  after  making  a  false  passage  consists  in  rest  in  bed,  urethral 
and  urinary  antisepsis,  continuous  catheterization  for  some  days,  and 
the  avoidance  of  further  instrumentation  for  some  weeks.  Should  peri- 
neal abscess  or  urinary  infiltration  follow,  prompt  incision  is  indicated. 

If  a  sound  is  passed  through  a  stricture  of  small  cahbre,  it  should 
remain  five  or  ten  minutes,  and  then  be  withdrawn.  If  it  is  the  first 
experience  with  the  patient,  it  is  best  to  wait  three  or  four  days  before 
passing  an  instrument  again,  in  the  mean  time  administering  five-grain 
doses  of  salol  or  boric  acid  four  to  six  times  daily,  with  a  full  dose  of 
c{uinine  morning  and  evening.  At  the  next  sitting  it  is  well  to  recom- 
mence with  the  same  instrument,  after  which  one,  two,  or  three  larger 
sizes  may  be  used  in  succession,  provided  their  introduction  is  easy 
and  not  accompanied  by  pain  or  bleeding.  Hemorrhage  and  pain 
are  indications  for  lengthening  the  intervals  between  treatments  and 
for  proceeding  more  slowly  in  the  use  of  larger  instruments. 


240  GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 

Once  fairly  established,  however,  the  treatment  by  dilatation  is 
carried  on  until  the  full  normal  calibre  is  reached  :  usually  this  requires 
from  three  to  six  weeks. 

If  the  stricture  is  not  resilient  or  irritable,  and  is  not  traumatic  in 
its  origin,  it  will  be  found  that  all  symptoms  have  disappeared,  unless 
perhaps  the  gleet  persists  for  a  time.  This,  too,  will  often  subside  ; 
but,  in  view  of  the  extensive  and  serious  urethral  lesions  always 
associated  with  long-standing  stricture,  it  is  apparent  that  gleet  may 
persist  in  spite  of  full  dilatation,  even  though  it  is  reinforced  by  most 
careful  local  and  general  treatment. 

When  the  stricture  is  a  recent  one,  absorption  may  tafce  place, 
but  in  any  event  the  occasional  introduction  of  a  steel  sound  by  the 
patient  will  always  keep  the  case  under  control. 

In  cases  of  resilient^  irritable^  or  traumatie  stricture  of  the  bulbo- 
membranous  region,  external  perineal  urethrotomy  is  the  operation 
of  choice.  Similar  strictures  of  the  penile  urethra  should  be  treated 
by  internal  urethrotomy. 

Strictures  of  Small  Calibre  permeable  only  to  Filiform  Bougies. — 
In  certain  cases  no  steel  sound  or  ordinary  soft  instrument  can  be 
made  to  pass  the  stricture,  but  a  persevering  trial  with  whalebone 
filiform  bougies  will  result  in  the  passage  of  one  into  the  bladder. 
This  trial  should  be  made  persistently  and  patiently,  and  in  the  ab- 
sence of  retention  of  urine  may  be  frequently  repeated.  After  anaes- 
thetizing the  urethra  and  relieving  local  congestion  by  an  instillation 
of  adrenalin  chloride,  1  to  2000  in  a  four  per  cent,  eucaine  solution,  the 
urethra  is  slightly  overdistended  anterior  to  the  stricture  by  carbolized 
oil  injected  by  means  of  a  piston  syringe.  A  filiform  is  passed  down 
to  the  stricture,  and  if,  after  patient,  gentle  effort,  it  refuses  to  enter,  it 
is  withdrawn,  and  is  given  an  angle  of  forty-five  degrees  by  bending  it 
across  the  thumb-nail  at  about  a  quarter  of  an  inch  from  the  end. 
(Fig.  76.)  As  the  orifice  of  a  tight  stricture  is  frequently  not  in  the 
middle  of  the  obstructed  urethra,  but  at  some  point  around  its  cir- 
cumference, this  manoeuvre  will  often  enable  the  surgeon  to  enter  it 
when  with  a  perfectly  straight  instrument  he  cannot  do  so.  If  this 
does  not  succeed,  several  fihforms  are  passed  by  the  side  of  the  first 
one,  to  impinge  on  the  irregular  surface  of  the  stricture  at  a  number  of 
points  ;  then  by  attempting  to  pass  first  one  and  then  another  of  these 
the  filiform  bearing  the  right  relation  to  the  orifice  will  usually  be  found 
and  can  be  introduced  into  the  bladder.  If  this  fails  and  one  filiform 
can  merely  be  engaged  in  the  stricture,  it  is  often  best,  in  the  absence 
of  retention,  to  tie  it  in  place  and  allow  it  to  remain  for  twenty-four 
hours.     In  the  great  majority  of  cases  at  the  end  of  this  time  it  can 


^ 


STRICTUKE    OF    THE    URETHRA.  241 

be  passed  through  the  stricture.     After  the  first  instrument  is  intro- 
duced, four  courses  are  open  to  the  surgeon. 

A.  Continuous  Dilatation. — 1.  The  filiform  may  remain  in  place, 
with  the  certainty  that  in  one  or  two  days  others  may  be  slipped  along- 
side of  it,  and  may  be  used  as  guides  for  the  introduction  first  of  a 
tunnelled  catheter  and  later  of  an  ordinary  soft  or  steel  instrument. 

2.  An  immediate  attempt  may  be  made  to  pass  into  the  bladder  a  tun- 
nelled catheter,  and  if  successful  leaving  it  to  act  for  twenty-four  hours 
by  continuous  dilatation ;  later,  gradual  dilatation  may  be  employed. 

B.  Urethrotomy. — 3.  A  tunnelled  and  grooved  staff  may  be  passed 
over  the  filiform,  and  external  urethrotomy  may  be  performed. 

4.  The  filiform  may  be  used  as  a  guide  for  a  Maisonneuve  urethro- 
tome, and  internal  urethrotomy  may  be  performed. 

If  the  stricture  which  is  being  dealt  with  is  not  of  traumatic 
origin,  and  is  not  specially  resilient  or  irritable,  the  first  method  will 
lead  to  the  adoption  of  gradual  dilatation  with  the  greatest  degree  of 
comfort  and  absence  of  anxiety  to  both  the  patient  and  the  surgeon. 
Even  if  there  has  been  moderate  retention,  it  is  certain  that  the  urine 
will  pass  with  increasing  freedom  by  the  side  of  the  filiform,  and  that 
the  danger  of  the  case  is  over  so  far  as  retention  is  concerned. 

If  retention  has  been  complete  for  many  hours  and  it  is  necessary 
to  give  immediate  relief  to  the  overstretched  bladder-walls,  it  is  best 
to  adopt  the  second  method, — that  is,  pass  a  catheter  at  once.  Failing 
in  this,  the  third  method,  or  external  perineal  urethrotomy,  should  be 
employed.  In  all  deep  strictures  when  instrumentation  occasions 
rigors  the  external  cutting  operation  is  indicated. 

Internal  urethrotomy  is  practised  in  cases  of  tight,  bulbo-mem- 
branous  stricture  complicated  by  retention  only  when  the  patient  re- 
fuses to  have  the  external  operation  performed.  In  the  best  hands 
it  is  attended  with  a  distinctly  larger  mortality  than  any  of  the  other 
methods  mentioned,  and  there  is  no  evidence  that  it  is  followed  by 
any  larger  percentage  of  permanent  cures. 

While  gradual  dilatation  is  the  preferable  treatment  in  the  great 
majority  of  cases,  there  are  a  number  of  strictures  in  which  it  is  not 
appHcable,  and  which  are  best  treated  by  other  methods. 

URETHROTOMY. 

A  stricture  may  be  divided  entirely  from  within  the  urethra,  in 
which  case  the  operation  is  termed  internal  urethrotomy  ;  it  may  be 
divided  by  an  incision  carried  through  the  overlying  integument  and 
fascia, — external  urethrotomy  ;  or  both  of  these  methods  may  be  em- 
ployed,  COMBINED  INTERNAL  AND  EXTERNAL  URETHROTOMY. 


242  GEJSriTO-UKINARY   DISEASES   AND    SYPHILIS. 

Internal  Urethrotomy. — The  different  methods  employed  in 
the  internal  division  of  stricture  depend  upon  the  direction  and  loca- 
tion of  the  incision.  This  may  be  made  (a)  from  before  backward  or 
(b)  from  behind  forward ;  (c)  on  the  roof  or  (d)  on  the  floor  of  the 
urethra. 

For  operations  on  narrowings  of  the  meatus  or  those  placed  within 
the  navicular  portion  of  the  urethra'  an  ordinary  blunt-pointed  teno- 
tome with  a  convex  cutting  edge  is  all  that  is  required.  But  for  opera- 
tions at  a  greater  depth  a  number  of  instruments  have  been  devised, 
for  each  of  which  some  special  merit  is  claimed. 

In  cutting  strictures  at  or  anterior  to  the  bulb  the  incision  is  made 
in  the  roof  of  the  urethra,  except  at  the  meatus,  where  the  incision  is, 
as  a  rule,  made  on  the  floor.  The  division  of  stricture  of  the  mem- 
branous urethra  is  less  liable  to  be  attended  with  troublesome  hemor- 
rhage if  the  incision  is  made  on  the  urethral  floor.  Gonorrhoea! 
strictures  are  fortunately  not  frequent  in  this  portion  of  the  canal. 

If  the  hemorrhage  is  not  controlled  by  the  catheter  alone,  a  firm 
bandage  should  be  applied  to  the  penis,  or,  if  the  point  of  cutting  is 
too  deep  to  be  reached  in  this  way,  pressure  may  be  applied  to  the 
perineum  by  a  compress  placed  over  the  seat  of  operation  and  the 
application  of  a  crossed  of  the  perineum.  For  the  temporary  arrest 
of  active  hemorrhage  perineal  pressure  apphed  by  a  padded  cane,  the 
ferrule  of  which  is  braced  against  the  foot-board  of  the  bed,  will  be 
found  efficient,  or  digital  compression  may  be  made  by  an  attendant. 

The  antiseptie  details  required  in  internal  urethrotomy  are  as  fol- 
lows. For  from  five  to  seven  days  before  operation  salol  and  boric 
acid  should  be  given  by  the  mouth, — five  grains  of  the  former  and 
ten  grains  of  the  latter  four  times  daily.  This  is  particularly  indi- 
cated when  cystitis  is  present  and  the  urine  is  infected.  The  urethra 
is  rendered  as  surgically  clean  as  possible  by  previous  irrigation 
repeated  night  and  morning  for  several  days  before  operation,  with 
a  final  washing  just  before  the  introduction  of  the  urethrotome. 
The  solutions  used  are  normal  saline,  a  1  to  4000  lotion  of  potassium 
permanganate,  a  1  to  5000  solution  of  silver  nitrate,  or  a  1  to  1000 
protargol  solution.  If  the  stricture  is  permeable,  a  soft  catheter  of 
small  calibre  is  passed  behind  it  and  the  whole  urethra  is  flushed  out 
with  the  cleansing  lotion,  from  eight  ounces  to  a  pint  being  used  each 
time ;  or  the  washing  is  conducted  with  the  gravity  bag  and  short 
urethral  nozzle.  The  instrument  employed  is  boiled  in  soda  solution 
(one  per  cent.)  for  ten  minutes  before  it  is  used. 

After  the  stricture  is  divided,  a  full-sized  soft  rubber  catheter  is 
passed  into  the  bladder  and  retained  there  for  twenty-four  hours.     As 


STRICTUKE    OF    THE    URETHRA.  243 

it  is  withdrawn,  a  1  to  2000  protargol  lotion  is  allowed  to  flow 
through  it,  thus  flushing  the  urethra  and  cleansing  the  seat  of  opera- 
tion. The  catheter  should  be  a  new  one,  and  should  be  disinfected 
by  boiling  immediately  before  operation. 

Indications  for  the  Performance  of  Internal  Urethrotomy. — This 
operation  is  indicated :  1.  In  all  strictures  at  or  near  the  meatus. 

2.  In  tibrous,  resilient,  or  irritable  strictures  of  large  calibre  ante- 
rior to  the  bulbo-membranous  juncture. 

3.  In  strictures  of  small  calibre  situated  in  advance  of  the  bulbo- 
membranous  juncture,  except  when  such  strictures  are  very  recent, 
soft,  and  dilatable. 

Or,  still  further  to  simplify  the  indications,  it  may  be  stated  that 
all  fibrous,  resihent,  or  irritable  strictures  anterior  to  the  bulbo- 
membranous  juncture  should  be  treated  by  internal  urethrotomy. 

Resiliency  and  resistance  to  dilatation  are  the  chief  indications  for 
preferring  the  cutting  operation  in  the  treatment  of  strictures  of  any 
portion  of  the  urethral  tract :  hence,  even  though  the  coarctations  are 
of  large  calibre,  if  they  are  distinctly  resilient  or  fibrous  urethrotomy 
is  indicated. 

Strictures  of  small  calibre  situated  in  advance  of  the  bulbo-mem- 
branous juncture,  unless  seen  very  early  and  found  to  be  soft  and 
dilatable,  furnish  the  typical  condition  for  internal  urethrotomy.  In 
such  cases  the  operation  is  attended  with  the  greatest  prospect  of  a 
permanent  cure.  The  exceptions  to  this  rule  will  be  given  in  the 
section  devoted  to  combined  internal  and  external  urethrotomy. 

For  strictures  of  the  meatus  and  in  the  neighborhood  of  the  fossa 
navicularis  dilatation  is  peculiarly  unsatisfactory,  since  the  excessive 
sensibility  of  this  part  and  the  intimate  relation  between  the  spongy 
tissue  of  the  glans  and  the  urethra  make  stretching  painful  and  render 
inflammatory  reaction  unduly  severe. 

The  incision  is  made  on  the  floor  of  the  urethra,  and  should  be 
sufficiently  deep  to  remove  all  sense  of  resistance  upon  the  withdrawal 
of  a  bulbous  bougie  two  numbers  larger  than  the  normal  urethral 
calibre,  since  there  is  always  slight  contraction  in  healing.  A  ten  per 
cent,  solution  of  cocaine,  applied  by  means  of  a  pledget  of  cotton 
wrapped  on  a  match-stick  dipped  in  the  solution,  passed  into  the 
meatus  and  held  in  place  for  two  minutes,  will  render  the  operation 
entirely  painless.  The  incision  should  be  made  exactly  in  the  middle 
line,  and  bleeding  may  be  checked  by  packing  the  navicular  fossa 
with  iodoform  gauze.  A  short  straight  conical  bougie  of  full  size, 
the  so-called  meatus  sound  (Fig.  64),  should  be  gently  inserted  once 
daily  during  the  healing  process.     Applications  of  cocaine  render  this 


244 


GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 


procedure  practically  painless,  and  also  relieve  the  ardor  urinae  of 
which  some  patients  complain.  Deeper-seated  troubles,  unless  urgent 
in  their  character,  should  be  ignored  until  the  healing  is  complete. 

Internal  Urethrotomy  from  before  backward.— The  best  instru- 
ment for  performing  this  operation  is  Maisonneuve's  urethrotome 
(Fig.  87),  or  one  of  its  modifications,  as  described  by  Teevan.     The 

Fig.  87. 


Maisonneuve's  urethrotome. 


Maisonneuve  urethrotome  is  provided  with  screw-tipped  filiform  bou- 
gies, which  are  first  passed  through  the  stricture  into  the  bladder. 
The  tip  is  then  screwed  to  the  urethrotome,  and  the  latter  is  intro- 
duced, accurately  guided  by  the  filiform. 

In  Teevan's  urethrotome  (Fig,  88)  the  groove  of  the  staff  termi- 
nates two  inches  from  the  end.     By  means  of  a  stylet  a  triangular 

Fig.  88. 


Teevan's  urethrotome. 


blade  contained  in  a  double  sheath  is  made  to  slide  along  this  groove 
and  to  expose  its  cutting  edge  when  the  stricture  is  reached.  A 
screw  on  the  end  of  the  staff  is  provided  for  the  attachment  of  the 
filiform  bougie.  By  the  withdrawal  of  the  stylet  the  instrument  is 
converted  into  a  catheter,  thus  allowing  the  surgeon  to  assure  himself 
that  the  instrument  has  certainly  passed  into  the  bladder  by  the  proof 
afforded  by  escape  of  urine.  Both  these  instruments  divide  the  stric- 
ture on  the  urethral  floor  to  a  sufficient  extent  to  allow  of  the  passage 


STEICTURE    OF   THE    URETHRA.  245 

of  a  dilating  urethrotome,  by  means  of  which  an  incision  in  the  roof 
of  the  urethra  can  be  made,  restoring  it  to  its  normal  cahbre. 

Cutting  the  stricture  from  before  backward  is  thus  performed.  A 
fine,  flexible,  guiding  bougie  is  passed  into  the  bladder.  The  screw 
end  of  this  is  secured  to  the  urethrotome,  and  the  tip  of  the  latter  is 
passed  through  the  stricture  into  the  bladder  and  held  in  position  by 
an  assistant.  The  operator  with  his  left  hand  draws  the  penis  for- 
Avard  and  with  his  right  hand  pushes  the  sheathed  knife  down  the 
urethra  until  the  obstruction  is  reached.  The  cutting  edge  of  the 
knife  is  then  exposed  and  all  the  resisting  tissue  in  front  of  it  is 
divided.  The  knife  is  then  drawn  into  its  sheath,  and  the  latter  is 
pushed  along  the  urethra,  gliding  in  readily  if  the  division  has  been 
complete.  If  the  sheathed  knife  meets  with  an  obstruction  when  it 
is  pushed  forward,  the  incision  may  have  to  be  repeated ;  but  this  is 
undesirable.  If  the  stricture  is  thoroughly  divided,  the  instrument  is 
withdrawn  immediately  and  a  full-sized  silver  catheter  is  passed,  the 
bladder  emptied,  and  the  catheter  withdrawn.  If  the  stricture  is  not 
fully  divided, — and  this  is  usually  the  case  when  the  Maisonneuve 
or  Teevan  instrument  is  used, — the  foregoing  operation  may  be  re- 
garded as  a  preliminary  to  division  from  behind  forward  by  a  dilating 
urethrotome,  and  the  introduction  of  the  latter  instrument  (rendered 
possible  by  the  previous  incision)  should  be  the  next  procedure,  the 
incision  in  this  case  being  made  on  the  roof  of  the  urethra.  After 
the  operation  the  patient  is  put  to  bed  and  placed  on  quinine  and 
urinary  antiseptics, — i.e.,  salol  five  grains,  boric  acid  ten  grains,  each 
three  or  four  times  a  day. 

If  no  rigors  have  occurred  within  forty-eight  hours  after  the  oper- 
ation, a  sound  equal  in  size  to  the  catheter  is  passed  through  the 
divided  stricture.  The  patient  is  then  allowed  to  get  up,  the  sounds 
being  subsequently  passed  every  three  or  four  days,  then  every 
week,  etc. 

Internal  Urethrotomy  from  behind  forward. — Among  the  many 
instruments  devised  for  this  operation,  Civiale's  urethrotome,  or  some 
modification  of  it,  is  probably  the  best.  It  consists  of  a  slender 
straight  shaft  wilh  a  small  bulbous  end.  The  knife  is  concealed 
in  the  bulb,  and  by  a  simple  contrivance  in  the  handle  it  can  be 
projected  one,  two,  three,  or  four  degrees,  according  to  the  depth 
of  the  incision  required.  The  method  of  procedure  is  as  follows. 
The  stricture  having  been  dila^^ed  to  No.  10  or  No.  12  French,  the 
bulbous  end  of  Civiale's  urethrotome  is  passed  fully  one-half  or  three- 
quarters  of  an  inch  beyond  the  stricture,  the  knife  is  exposed  on  the 
roof  of  the  urethra,  is  held  firmly  in  place  in  its  relation  to  the  instru- 


246 


GEXITO-URINARY   DISEASES   AND   SYPHILIS. 


ment,  and  is  withdrawn  until  all  resistance  is  overcome.  The  blade 
is  then  sheathed  and  the  instrument  withdrawn.  A  full-sized  sound 
is  then  passed  into  the  bladder.  If  this  meets  with  any  obstruction, 
the  situation  is  noted,  the  urethrotome  is  reintroduced,  and  the  ob- 
structing tissue  is  divided. 

The  urethrotome  invented  by  Otis  is  very  useful  in  the  treatment 
of  strictures  of  large  calibre.  It  is  constructed  on  the  principle  of 
the  parallel  ruler,  and  when  closed  measures  18  (French).  The 
bars  are  separated  by  means  of  a  screw  apparatus  at  the  handle, 
the  amount  of  separation  being  registered  on  a  dial.  A  sheathed 
knife  runs  in  a  groove  cut  in  the  upper  bar  of  the  instrument.  The 
urethrotome  is  introduced  beyond  the  stricture  and  then  dilated  up 
to  or  a  millimetre  or  two  above  the  normal  calibre,  in  order  to  make 
the  fibrous  bands  completely  salient ;  then  the  blade  is  drawn  through 
the  entire  area  of  narrowing. 

Fig.  89. 


Gerster's  urethrotome. 


Gerster's  urethrotome  (Fig.  89)  is  constructed  on  the  same  general 
principles  as  that  of  Otis,  but  possesses  the  advantages  of  more  ac- 
curately locating  the  seat  of  narrowing  and  of  being  readily  taken 
apart,  so  that  it  can  be  thoroughly  cleansed  after  use. 

Gross's  urethrotome  serves  as  an  exploring  and  a  cutting  instru- 
ment at  the  same  time.  When  the  shoulder  of  the  bulb  is  brought 
up  to  the  posterior  face  of  the  stricture  the  concealed  blade  can  be 
protruded  and  the  stricture  divided  as  the  instrument  is  withdrawn. 

The  choice  of  the  urethrotome  is  of  small  moment  in  the  internal 
cutting  of  stricture.  The  essential  feature  of  the  operation  is  that 
a  linear  incision  should  be  made  in  the  roof  of  the  urethra  (except 
at  or  near  the  meatus  or  in  the  membranous  urethra)  through  every 
portion  of  stricture  tissue,  the  cut  extending  from  the  normal  parts 
behind  to  the  normal  parts  in  front  of  the  stricture  and  enabling  the 
surgeon  to  pass  at  once  an  instrument  two  sizes  larger  than  the 
normal  calibre  of  the  urethra. 

If  the  narrowing  is  of  very  small  calibre,  a  preliminary  urethrot- 


STKICTURE    OF   THE    UEETHRA.  247 

omy  from  before  backward  may  be  done  with  Maisomieuve's  instru- 
ment, after  which  a  dilating  urethrotome  completes  the  operation 
from  behind  forw^ard.  Careful  observance  of  the  principles  of  urethral 
and  urinary  antisepsis  as  already  described  (page  230)  reduces  to  its 
minimum  the  risk  always  attendant  on  internal  urethrotomy. 

In  children  internal  urethrotomy  has  the  same  applications  as  in 
the  adult,  but  the  urethrotome  must  be  modified  in  calibre  and  length 
to  suit  the  age  of  the  individual  patient. 

External  Perineal  Urethrotomy. — By  this  operation  the 
urethra  is  opened  by  an  incision  carried  imvard  from  the  skin  sur- 
face of  the  perineum.  In  accordance  with  the  calibre  of  the  stric- 
ture, certain  modifications  will  be  necessary  in  the  performance  of 
this  operation. 

Thus,  if  the  stricture  is  permeable,  1,  external  perineal  urethrotomy 
with  a  guide,  or  Syme's  operation,  is  indicated,  a  grooved  staff  being 
carried  through  the  narrowing  and  the  incision  being  made  on  this. 

If  the  stricture  is  impermeable,  2,  external  perineal  urethrotomy 
without  a  guide,  or  ^''perineal  section,''''  is  indicated,  a  staff  being  carried 
down  to  the  anterior  face  of  the  stricture  and  the  urethra  being 
opened  at  this  point ;  subsequently,  aided  by  sight,  the  stricture  is 
divided  from  before  backward. 

1.  External  Perineal  Urethrotomy  with  a  Guide,  or  Syme's  Oper- 
ation.—The  instruments  required  for  this  operation  are  a  grooved 
staff,  a  scalpel,  a  probe,  a  broad  grooved  director,  or  a  Teale's  probe 
gorget  (Fig.  90),  and  a  soft  rubber  or  English  catheter  of  large  calibre. 
The  grooved  staff  (Fig.  91)  has  a  narrowed  terminal  part  which  is 
passed  through  the  stricture.  Where  this  narrow  portion  joins  the 
shaft  there  is  a  shoulder,  which  rests  against  the  anterior  face  of  the 
stricture  when  the  instrument  is  in  position.  The  patient  having 
been  etherized,  the  staff  is  introduced,  and  the  patient  is  placed  in 
the  hthotomy  position. 

Fig.  90. 


Teale's  probe-euded  gorget. 


The  use  of  the  Syme  staff  is  possible  only  when  the  stricture 
will  admit  at  least  a  No.  6  F.  instrument;  when  it  is  so  tight  that 
nothing  larger  than  a  filiform  bougie  can  be  passed,  a  grooved  staff' 


248 


GEISriTO-UKINARY   DISEASES   AXD   SYPHILIS. 


similar  to  Syme's,  but  with  a  quarter  of  an  inch  of  its  extremity 
bridged  over  so  as  to  convert  the  groove  mto  a  canal,  a  "  tunnelled  cath- 
eter staff"  (Fig.  92),  is  used,  and  is  threaded  over  a  filiform  bougie. 

In  passing  the  filiform  the  urethra  is  first  overdistended  with 
carbolized  oil,  then  the  filiform  is  gently  introduced.  If  it  enters 
a  false  passage  it  is  held  in  place,  w^hile  another  bougie  is  passed  by 
its  side.  The  second  is  allowed  to  remain  where  it  is  arrested,  and 
other  bougies  are  passed,  some  straight-tipped,  others  angled  or  cork- 

FiG.  91. 


Syme's  grooved  staff. 

screwed,  till  finally  one  goes  through  the  stricture  into  the  bladder. 
The  other  guides,  often  five  or  six  in  number,  are  then  withdrawn. 
The  tunnelled  staff  is  threaded  over  the  free  end  of  the  filiform,  and 
is  gently  pushed  towards  the  bladder,  the  guide  being  held  by  the 
left  hand.  It  is  best  to  release  this  guide,  if  the  strain  and  friction 
become  great,  and  allow  it  to  be  pushed  onward  with  the  staff.  Its 
end  will,  of  course,  disappear  within  the  urethra,  but  can  usually  be 


Fig.  92. 


Tunnelled  catheter  staff. 

found  again  within  an  inch  of  the  meatus  by  pressing  the  penis  back- 
ward after  the  metalhc  instrument  is  in  the  bladder ;  if  it  cannot  be 
found  thus,  it  will  certainly  reappear  when  the  staff  is  w-ithdrawn. 

In  whatever  way  the  staff  has  been  passed,  the  assistant  who  holds 
it  is  directed  to  make  its  convexity  bulge  in  the  perineum.  The  left 
forefinger  of  the  operator  is  inserted  into  the  rectum,  and  an  incision 
is  made  one  inch  in  front  of  the  anus  and  exactly  in  the  median  line 
of  the  perineum.  This  incision  is  deepened  till  the  knife-point  enters 
the  groove  of  the  narrow  part  of  the  staff,  usually  behind  the  stricture. 
The  latter  is  then  divided  by  cutting  from  behind  forward  until  the 
projecting  shoulder  of  the  staff  is  freed  and  passes  onward  towards 
the  bladder  without  difficulty.  A  director  or  Teale's  probe  gorget  is 
now  introduced  along  the  groove  of  the  staff  into  the  bladder,  and  the 
staff  is  withdrawn.     Finally,  a  rubber  catheter.  No.  24  to  No.  28  F., 


STRICTURE    OF    THE    URETHRA.  249 

is  passed  from  the  meatus  into  the  bladder,  guided  by  the  director  or 
gorget,  and  aided  in  its  course  by  manipulation  through  the  wound. 
This  catheter  is  retained  for  three  days,  and  is  then  withdrawn. 
Should  urethral  or  vesical  irritability  prevent  the  retention  of  a 
catheter,  a  tube  may  be  passed  into  the  bladder  through  the  perineal 
wound  and  retained  in  position  by  silk  threads  secured  to  a  J  band- 
age. In  from  five  to  seven  days  a  full-sized  sound  is  passed  through 
the  penile  urethra  into  the  bladder,  and  this  is  repeated  every  third 
day  for  a  month,  after  which  the  intervals  between  instrumentation 
may  be  made  progressively  longer.  • 

If  the  filiform  passes  but  the  tip  of  the  tunnelled  staff  cannot  be 
forced  through  the  stricture,  the  latter  is  held  in  contact  with  the 
anterior  surface  of  the  narrowing  by  an  assistant,  and  is  exposed  by 
a  free  incision  in  the  median  line  of  the  perineum,  splitting  the  urethra 
in  front  of  the  stricture  ;  a  loop  of  silk  is  then  passed  through  each 
edge  of  the  divided  urethra  close  to  the  face  of  the  narrowing,  thus 
enabhng  the  canal  to  be  held  open.  The  staff  is  withdrawn  a  little 
in  order  to  bring  the  black  filiform  into  view,  and  then  the  stricture 
is  divided  from  before  backward,  together  with  half  an  inch  of  the 
uncontracted  canal  behind  it,  by  means  of  a  probe-tipped  bistoury. 
The  last  step  consists  in  passing  the  staff',  guided  by  the  fdiform,  into 
the  bladder.  The  subsequent  treatment  is  the  same  as  in  Syme's 
operation. 

The  general  indication  for  external  urethrotomy  is  the  existence  in 
the  deep  urethra — i.e.,  posterior  to  the  bulbo-membranous  juncture — 
of  a  stricture  not  amenable  to  dilatation.  Under  this  head  will  come 
a  great  variety  of  strictures,  which  may  be  classified  as  follows. 

1.  Stricture  which  is  resilient  or  so  densely  fibrous  that  it  will 
not  jrield  to  either  continuous  or  intermittent  dilatation.  Traumatic 
stricture  is  typical  of  this  class  of  cases.  2.  Stricture  behind  which 
extravasation  of  urine  has  occurred.  3.  Stricture  complicated  with 
perineal  abscess,  the  latter  being  laid  open  at  the  same  time  that 
the  stricture  is  divided.  4.  Stricture  complicated  with  fistulas  which 
do  not  close  after  full  dilatation.  5.  Stricture  complicated  with  a  cys- 
titis so  intense  that  continuous  drainage  of  the  bladder  is  indicated. 
6.  Stricture  associated  with  enlargement  of  the  prostate  and  refusing 
to  yield  to  dilatation.  7.  Stricture  complicated  with  retention  of  urine 
or  with  the  "  incontinence  of  retention."  The  high  degree  of  atony 
of  the  bladder  which  ordinarily  exists  in  these  cases  renders  perineal 
drainage  exceptionally  desirable.  8.  Stricture  in  which  urethral  fever 
follows  instrumentation,  or  in  which  renal  congestion  or  nephritis  is 
known  to  exist. 


250  genito-ukijSTAEy  diseases  and  syphilis. 

The  Prognosis  of  Stricture  after  External  Perineal  Urethrotomy. — 
The  thorough  division  of  stricture  by  external  urethrotomy  occa- 
sionahy  results  in  cure  without  further  treatment.  This,  according 
to  Guyon,  is  because  the  elastic  fibres  of  the  urethra  run  circularly ; 
when  cut  they  retract,  and  restoration  of  the  urethral  lumen  is  accom- 
plished by  means  of  a  wide  scar,  which  usually  does  not  contract 
sufficiently  to  produce  stricture  again. 

It  is  possible  that  recent  strictures  unattended  by  submucous 
fibroid  infiltration  can  be  cured  either  by  gradual  dilatation  or  by 
section.  When  there  is  distinct  fibroid  periurethral  infiltration,  with 
decided  alteration  of  the  mucous  membrane,  section,  followed  by  a 
prolonged  course  of  gradual  dilatation,  will  usually  accomplish  a 
practical  but  not  a  truly  radical  cure.  In  densely  fibrous  inodular 
stricture  a  radical  cure  can  be  attempted  only  by  means  of  excision, 
and  even  then  will  probably  not  be  attained  :  hence,  though  a  stric- 
ture be  cut,  either  internally  or  externally,  the  intermittent  use  of  the 
sound  for  a  long  period  should  be  advised. 

Combined  Internal  and  External  Urethrotomy. — This  operation  is 
described  by  Reginald  Harrison,  its  chief  advocate,  as  follows :  The 
stricture  is  divided  by  means  of  a  urethrotome.  The  patient  is  then 
placed  in  the  lithotomy  position,  a  grooved  staff  is  introduced,  and,  with 
a  long,  straight  knife  entered  one  inch  in  front  of  the  anus,  the  mem- 
branous urethra  is  punctured,  the  back  of  the  knife  being  towards  the 
rectum.  The  incision  is  slightly  enlarged  forward,  to  permit  the  in- 
troduction of  the  index  finger.  If  the  staff  is  not  fully  exposed,  a 
somewhat  dull  though  pointed  knife  is  introduced  along  the  finger, 
and  the  tissue  still  remaining  between  the  tip  of  the  finger  and  the 
groove  is  cleared  away.  If  a  sharp  knife  is  used,  there  is  danger  of 
making  the  incision  unnecessarily  large  or  of  cutting  the  finger.  The 
incision  is  planned  first  to  fit  the  finger  and  afterwards  the  drainage- 
tube.  When  the  groove  of  the  staff'  is  felt,  a  probe-tipped  gorget  is 
slid  along  it,  the  staff'  is  removed,  and  a  drainage-tube  is  passed  along 
the  concavity  of  the  gorget  into  the  bladder.  This  tube  drains  the 
bladder  directly,  giving  the  urethra  physiological  rest.  It  is  retained 
seven  to  ten  days ;  after  the  second  day  it  is  taken  out  and  cleansed 
daily,  and  the  bladder  is  irrigated  twice  daily  with  a  1  to  10,000  or  1 
to  5000  sublimate  solution. 

This  operation  possesses  the  advantage  of  preventing  the  freshly 
cut  stricture  from  being  irritated  by  the  urine.  Since  contact  with 
urine  is  an  essential  factor  in  the  production  of  organic  stricture, 
such  a  diversion  of  the  stream  during  attempts  at  radical  cure  is 
worthy  of  consideration  whenever  resilient,  inodular.  or  traumatic 


STKICTURE    OP    THE    URETHRA.  251 

anterior  strictures  are  cut,  or  whenever  the  coarctation  is  complicated 
by  fistulse ;  physiological  rest  is  thus  obtained  for  the  whole  region, 
and  the  inflammatory  products  in  the  wall  of  the  urethra  are  allowed 
to  undergo  fatty  degeneration  and  absorption.  In  deep  strictures  the 
combined  operation  is  less  likely  to  be  useful,  as  external  urethrotomy 
meets  the  same  indications,  the  incision  being  carried  behind  the  stric- 
tured  region  into  healthy  tissue  and  the  retained  catheter  serving  to 
divert  the  urine. 

Harrison,  however,  particularly  recommends  his  operation  in 
cicatricial,  contractile,  and  relapsing  strictures  seated  in  the  deeper 
part  of  the  urethra,  claiming  for  it  the  following  advantages :  1.  It  is 
applicable  to  the  worst  forms  of  urethral  strictures,  2.  It  guards 
against  rigors,  fever,  and  the  complications  which  tend  to  rise  from 
these.  3.  It  tends  to  improve  permanently  the  condition  of  the 
stricture. 

Experience  has  shown  that  if  the  tissues  can  be  freed  from  every 
source  of  irritation  and  can  be  given  physiological  rest  for  a  long 
period,  hardened  lymph  will  disappear  and  the  urethral  walls  again 
will  become  soft  and  yielding.  Drainage  by  perineal  opening  is  the 
only  way  in  which  complete  rest  can  be  given  to  the  strictured  region. 

Perineal  Section. — This  operation-  is  reserved  for  strictures 
through  which  the  smallest  instrument  cannot  be  made  to  pass. 
Such  strictures,  whether  gonorrhoeal  or  traumatic,  are  usually  deeply 
seated,  and  are  approached  through  the  perineum. 

A  special  hooked  staff  (Fig.  93)  is  required.  In  addition  to  a  probe- 
tipped  gorget,  scalpel,  forceps,  needles,  etc.     The  patient  is  placed  in 

Fig.  93. 


WheeUioiise's  staff. 

the  lithotomy  position,  and  the  staff  is  introduced  with  the  groove 
towards  the  floor  of  the  urethra,  its  hooked  extremity  being  brought 
gently  into  contact  with  the  stricture.  No  force  is  permissible, 
since  the  urethra  in  these  cases  is  readily  torn.  While  an  assistant 
holds  the  staff  in  position,  an  incision  is  made  in  the  perineum, 
and  the  urethra  is  exposed,  and  is  opened  in  the  groove  of  the 
staff,  not  upon  its  point,  thus  making  the  incision  at  least  a  quarter 
of  an  inch  in  front  of  the  stricture,  since  the  groove  is  not  continued 
to  the  hook-shaped  extremity  of  the  staff.  Through  the  edges  of 
the  urethral  incision  are  passed  by  means  of  curved  needles  stout 
silk  threads,  one  on  each  side,  forming  loops,  by  drawing  on  which 


252  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

the  urethral  walls  are  retracted.  The  staff  is  gently  withdrawn  until 
the  button  point  appears  in  the  wound.  It  is  then  turned  around 
so  that  the  groove  faces  the  roof,  and  the  button  is  hooked  in 
the  upper  angle  of  the  open  urethra.  The  urethra  is  now  stretched 
open  at  three  points  just  in  front  of  the  stricture.  The  button  on  the 
staff,  however,  is  often  in  the  way,  and,  if  so,  this  instrument  should 
be  withdrawn.  With  the  anterior  surface  of  the  stricture  thus  ex- 
posed, the  narrow  opening  through  it  is  often  seen,  and  a  probe- 
pointed  director  is  passed  without  difficulty.  Even  if  w^arty  growths 
or  granulations  conceal  the  position  of  the  narrowed  channel,  careful 
probing  with  the  director  usually  results  in  the  ready  passage  of  the 
latter  into  the  bladder ;  this  is  shown  by  the  freedom  with  which  the 
tip  of  the  director  can  be  moved  about.  The  groove  of  the  director  is 
then  turned  downward,  and  along  it  the  whole  length  of  the  stricture 
is  carefully  and  fully  divided,  this  part  of  the  operation  being  completed 
by  running  a  straight  probe-pointed  bistoury  along  the  groove  to 
insure  the  cutting  of  every  band.  Teale's  gorget  is  now  passed  along 
the  groove  of  the  director  into  the  bladder,  and  the  director  is  with- 
drawn. The  object  of  the  gorget  is  to  facilitate  the  introduction  of 
catheters  into  the  bladder,  at  times  a  most  difficult  ]3rocedure  after 
perineal  section.  A  full-sized  soft  rubber  catheter  is  passed  from  the 
meatus  into  the  bladder,  the  gorget  is  withdrawn,  and  the  catheter  is 
fastened  in  the  urethra.  After  three  or  four  days  the  catheter  is 
removed.  Sounds  are  then  passed  daily  or  every  second  day  or  every 
third  day,  according  to  circumstances,  until  the  wound  in  the  perineum 
is  healed,  and  after  that  from  time  to  time  to  prevent  recontractibn. 

If  the  probe-pointed  director  does  not  find  the  opening  through 
the  stricture,  the  operation  must  be  continued  by  dissection  until  the 
urethra  is  fairly  opened.  If  the  bladder  contains  urine,  pressure  on 
the  hypogastrium ,  or  bimanual  pressure,  one  hand  being  placed  on 
the  abdomen  and  a  finger  of  the  other  in  the  rectum,  will  often  cause 
the  expulsion  of  some  urine,  and  thus  show  the  opening  through  the 
stricture.  The  use  of  very  hot  water  will  sometimes  be  of  service  by 
emphasizing  the  difference  in  color  between  ths  surrounding  parts- 
and  the  urethra,  the  latter  being  much  paler. 

The  operation  requires  a  good  light,  and  often  much  patience. 

Indications  for  External  Perineal  Urethrotomy  ivithout  a  Guide. — 
Perineal  section  in  some  form  is  indicated  in  all  cases  of  impassable 
stricture.  If  there  are  no  other  compKcations,  Wheelhouse's  method 
is  the  best  to  employ.  But  in  cases  in  which  a  portion  of  the  urethra 
has  been  practically  destroyed,  in  which  urinary  extravasation  has 
occurred,  and  the  perineum  is  riddled  with  sinuses,  and  in  those  of 


STRICTURE    OF    THE    URETHRA.  253 

great  urgency  from  retention,  when  no  aspirating  apparatus  is  at 
hand,  Cock's  operation  is  indicated.  The  operation  is  a  difficult  one, 
is  sometimes  disappointing  in  the  best  hands,  and  should  be  aban- 
doned if  the  urethra  is  not  opened  at  the  first  or  the  second  trial. 

Retrograde  Catheterization. — When  all  guides  fail,  and  when  after 
perineal  section  the  proximal  end  of  the  urethra  cannot  be  found,  as 
in  cases  of  traumatic  stricture  with  practical  obliteration  of  the  canal, 
a  suprapubic  cystotomy  and  retrograde  catheterization  are  indicated. 
The  slight  additional  risk  is  far  outweighed  by  the  advantages  to  the 
patient  of  having  even  an  imperfect  restoration  of  the  urethral  canal. 

In  performing  retrograde  catheterization  the  suprapubic  opening 
into  the  bladder  is  made  sufficiently  large  to  admit  the  finger ;  guided 
by  the  latter,  which  can  readily  feel  the  vesical  orifice  of  the  urethra, 
a  steel  sound  or  a  silver  catheter  is  introduced  from  behind  forward 
till  its  tip  becomes  apparent  through  the  perineal  opening.  When 
the  belly  is  prominent  it  may  be  difficult  to  pass  an  ordinary  sound, 
by  Avay  of  the  small  vesical  opening,  into  and  through  the  prostatic 
and  membranous  portions  of  the  urethra.  To  obviate  this  difficulty 
Guyon  has  suggested  an  instrument  with  a  longer  or  more  com- 
plete curve  ;  in  the  absence  of  this,  an  English  gum  catheter,  provided 
Avith  a  stylet  and  with  the  required  curve  given  it  and  fixed  for  the 
time  by  immersing  the  instrument  in  cold  water,  may  be  employed. 
As  soon  as  the  tip  is  freely  exposed  through  the  perineal  wound,  a 
soft  catheter,  the  end  of  which  has  been  cut  off,  is  slipped  over  it ;  on 
withdrawing  the  sound  this  catheter  is  carried  from  the  perineum 
through  the  suprapubic  opening.  A  sound  having  been  passed  from 
the  meatus  to  the  perineal  wound,  the  other  end  of  the  soft  catheter 
is  forcibly  pushed  over  its  tip  and  is  drawn  forward  till  it  projects  from 
the  meatus.     The  tube  is  left  in  place  for  from  five  to  seven  days. 

Drainage  after  External  Urethrotomy  and  Perineal  Section. — Drain- 
age should  be  provided  for  by  a  large  English  or  soft  rubber  catheter 
(No.  24  to  No.  28  F.),  passed  through  the  urethra  till  its  eye  is  just 
within  the  bladder^  and  retained  in  position  from  three  to  five  days. 
If  the  end  of  the  catheter  is  not  allowed  to  project  far  into  the  bladder, 
and  if  it  is  kept  clean  by  regular  antiseptic  injections  repeated  twice 
daily,  it  is  most  efficient  as  a  means  of  preventing  urethral  fever. 
After  removal  of  the  catheter  first  introduced,  regular  dilatation  at  short 
intervals  is  indicated. 

The  traumatic  urethritis  which  the  retained  catheter  or  the  fre- 
quent use  of  the  instrument  is  said  to  occasion  will  hardly  ever  occur 
when  antiseptic  irrigations  are  properly  used,  and  when  the  urine  is 
sterilized  by  the  administration  of  drugs  by  the  mouth. 


254  GENITO-URINAKY    DISEASES    AND   SYPHILIS. 

These  irrigations  must  cleanse  both  the  bladder  and  the  urethra. 
The  tube  from  an  irrigating  bag  containing  the  antiseptic  and  hanging 
two  feet  above  the  level  of  the  bladder  is  attached  to  the  catheter,  and 
the  latter  is  slowly  withdrawn  till  the  fluid  escapes  through  the  meatus 
or  through  the  perineal  wound.  The  urethral  mucous  membrane  is 
flushed  with  from  a  pint  to  a  quart  of  the  antiseptic,  after  which  the 
catheter  is  passed  in  till  its  eye  lies  just  within  the  bladder,  and  is 
secured  in  place  till  the  next  washing. 

Miscellaneous  Methods. — Excision. — A  number  of  successful 
cases  of  excision,  usually  for  traumatic  stricture,  have  been  reported 
by  Heusner,  Koenig,  Poncet,  and  others, 

Poncet  states  that  the  indications  for  urethrectomy  are  found  in  the 
existence  of  marked  fibrous  induration  encircling  the  perineal  urethra, 
and  in  a  history  of  previous  unsuccessful  operations. 

Rollet,  Southam,  Sapregko,  and  others  report  excellent  results 
from  excision  of  dense  fibrous  strictures,  with  subsequent  suturing  of 
the  urethra  over  a  catheter. 

Excision  with  Transplantation  of  Mucous  Membrane. — Wolfler  has 
reported  three  cases  in  which  he  employed  Thiersch's  method  of 
transplanting  epiderm  for  the  radical  cure  of  impermeable  stricture. 
The  strictured  portion  of  the  urethra  was  first  excised,  and  after- 
wards the  granulating  surface  was  entirely  covered  with  mucous 
membrane  dissected  from  a  prolapsed  uterus.  This  mucous  mem- 
brane was  kept  in  place  by  a  packing  of  iodoform  gauze  lubricated 
on  the  inner  side  with  vaseline.  The  first  patient  one  year  after, 
and  with  no  intermediate  treatment,  urinated  a  thick  stream.  The 
second  did  as  well,  but  the  observation  had  not  lasted  so  long.  The 
third  died  six  months  after  the  operation,  from  double  nephritis,  and 
the  autopsy  showed  a  continuous  mucous  membrane.  The  bounda- 
ries between  the  old  and  the  new  mucous  membrane  could  not  be 
clearly  demonstrated. 

Electrolysis. — The  evidence  adduced  in  favor  of  this  method  is 
insufficient  to  warrant  its  general  adoption,  and  does  not  even  justify 
a  belief  in  its  usefulness  in  the  average  case. 

DivuLsiON. — This  method  is  clumsy,  uncertain,  and  dangerous. 
Under  this  general  heading  may  be  included  forced  catheterization, 
immediate  progressive  dilatation,  tunnellization,  progressive  divulsion, 
and  the  modifications  of  this  latter  method.  All  involve  rupture 
of  the  mucous  or  submucous  tissue  to  an  indeterminable  extent 
and  to  an  uncertain  point,  and  have  all  the  disadvantages  of  internal 
urethrotomy,  with  the  superadded  risk  of  a  lacerated  and  contused 
wound  as  compared  with  an  incised  wound. 


STRICTUKE    OF    TPIE    URETHRA.  255 

SUMMARY   OF   TREATMENT. 

1.  Gradual  dilatation  is  indicated  as  the  treatment  of  choice  in  all 
recent,  soft,  or  dilatable  strictures  found  in  any  part  of  the  urethra, 
without  regard  to  the  calibre  of  such  strictures. 

2.  Continuous  dilatation  is  indicated  in  uncomplicated  strictures 
which  are  so  tight  that  no  instrument  larger  than  a  filiform  can  be  made 
to  pass.  This  continuous  dilatation  is  practised  till  a  small  metal  in- 
strument can  be  introduced, — No.  12  to  No.  16  F.  Then  the  normal 
calibre  of  the  urethra  is  restored  by  gradual  dilatation  or  by  cutting,  in 
accordance  with  the  nature  and  the  clinical  behavior  of  the  stricture. 

3.  Internal  urethrotomy  is  indicated  in  all  fibrous,  irritable,  and 
resilient  strictures  anterior  to  the  bulbo-membranous  juncture.  Nar- 
rowings  at  or  near  the  meatus  should  be  treated  by  the  knife  whenever 
it  is  apparent  that  they  are  responsible  for  definite  symptoms.  The 
division  is  here  made  on  the  floor  of  the  urethra.  All  other  anterior 
strictures  are  divided  along  the  roof. 

4.  External  perineal  urethrotomy  is  indicated  in  all  fibrous,  re- 
silient, or  irritable  strictures  situated  behind  the  bulbo-membranous 
juncture. 

5.  CoMRiNED  internal  AND  EXTERNAL  URETHROTOMY  is  indicated  ill  the 
treatment  of  anterior  strictures  which  are  unusually  dense  or  nodular 
and  which  are  complicated  by  fistulse. 

6.  Perineal  section,  or  external  perineal  urethrotomy  without  a 
guide,  is  indicated  in  the  treatment  of  impassable  stricture  of  the 
deep  urethra.  When  the  proximal  urethral  end  cannot  be  found, 
suprapubic  cystotomy  ondi  retrograde  catheterization  are  justifiable. 

7.  Excision  is  indicated  in  cases  of  impermeable  stricture,  nodular 
or  fibroid,  where  there  has  been  complete  destruction  of  mucous 
membrane.  When  so  much  tissue  is  removed  that  it  is  impossible 
to  bring  the  divided  urethral  ends  in  apposition,  transplantation  of 
mucous  membrane  is  indicated. 

Formulating  the  operative  indications  in  accordance  with  the 
clinical  features  of  the  stricture,  the  following  summary  of  treatment 
is  given. 

1.  Narro wings  at  or  near  the  meatus,  if  treated  at  all,  are  always 
cut. 

2.  Strictures  of  large  calibre  (greater  than  15  F.)  are  treated  by 
gradual  dilatation.  Cutting  is  almost  never  required  when  such  a 
stricture  is  in  the  deep  urethra ;  it  is  sometimes  necessary  when  the 
stricture  is  anterior  to  the  bulbo-membranous  juncture. 

3.  Strictures  of  small  calibre  are  treated   by  gradual  dilatation 


256  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

if  possible  ;  when  in  the  deep  urethra  they  often  require  external 
urethrotomy ;  when  anterior  to  the  bulbo-membranous  juncture  they 
usually  require  internal  urethrotomy. 

4.  Impermeable  strictures  are  treated  by  perineal  section,  followed 
at  times  by  excision  and  mucous  membrane  grafting, 

5.  Soft,  recent,  uncomplicated  strictures  are  always  dilated. 

6.  Fibrous,  nodular,  irritable  strictures  complicated  by  urinary 
fever,  fistula,  etc.,  are  always  cut. 

STRICTURE   OF  THE   FEMALE   URETHRA. 

Stricture  of  the  female  urethra  is  comparatively  rare.  In  cause  and 
symptoms  it  corresponds  with  the  like  condition  of  the  male  urethra. 
It  may  be  congenital  or  acquired,  and  the  acquired  stricture  may  be 
spasmodic,  inflammatory,  or  organic.  The  congenital  stricture  is,  as 
in  the  case  of  the  male,  usually  placed  at  or  near  the  urinary  meatus. 

Spasmodic  stricture,  that  due  to  muscular  spasm,  is  more  frequent 
than  in  the  male.  This  is  doubtless  owing  to  the  greater  reflex  sus- 
ceptibility of  women.  Familiar  examples  are  afforded  by  retention 
of  urine  due  to  fright,  exhaustion,  exposure,  urethritis,  caruncles,  etc. 

Inflammatory  stricture — i.e.,  encroachment  on  the  urethral  calibre 
by  acute  inflammatory  swelling — probably  never  becomes  sufficiently 
marked  to  produce  retention,  this  when  it  occurs  being  due  to  spasm 
reflexly  excited  from  the  hypersemic  and  hypersesthetic  areas. 

Organic  stricture  is  due  to  trauma,  commonly  inflicted  during 
childbirth,  or  to  inflammation,  usually  gonorrhoeal  in  nature,  but  is 
sometimes  occasioned  by  a  urethral  calculus,  or  by  the  virus  of 
chancre  or  chancroid,  or  by  irritating  applications.  The  urethral 
narrowing  is  due  to  the  contraction  of  the  fibrous  tissue  which  has 
been  deposited  in  the  walls  of  the  canal  as  an  inflammatory  infiltrate 
and  which  has  subsequently  become  organized.  Hermann  states  that 
in  old  women  there  is  found  stricture  due  to  general  fibroid  thickening 
of  the  urethra,  occurring  without  any  history  of  gonorrhoea  or  other 
discernible  cause.  The  seats  of  narrowing  are  oftenest  at  or  near  the 
meatus  and  near  the  neck  of  the  bladder.  The  stricture  is  usually 
single,  and  frequently  occasions  so  little  inconvenience  that  its  presence 
is  not  suspected  by  the  patient. 

Skene  states  that  organic  stricture  sometimes  occurs  at  the  junc- 
ture of  the  urethra  with  the  bladder,  and  that  even  though  it  be  of 
large  calibre  it  occasions  symptoms  out  of  all  proportion  to  the  amount 
of  narrowing  it  producer;  this  is  probably  because  there  is  infiltra- 
tion of  the  vesical  sphincter  and  interference  with  its  function.  Diffi- 
cult urination  and  retention  are  the  most  characteristic  symptoms. 


STRICTUEE    OF    THE    URETHEA.  257 

the  stricture  being  of  such  a  large  calibre  that  it  may  escape  detection 
by  the  bulbous  bougie. 

Symptoms. — The  symptoms  of  stricture  in  women  are  frequent 
urination,  dribbling  after  the  act,  the  passage  of  an  irregular  stream, 
and  often  urethral  discharge. 

At  times  the  only  symptom  is  an  occasional  attack  of  retention  of 
urine  occasioned  by  slight  causes,  such  as  exposure  or  fatigue,  and 
usually  ascribed  to  muscular  spasm.  Though  the  spasmodic  element 
is  in  these  cases  always  the  exciting  cause  of  the  retention,  the  pre- 
disposing cause  will  occasionally  be  found  to  be  a  urethral  stricture 
of  large  calibre. 

Difficult  urination  and  sometimes  retention  particularly  character- 
ize stricture  at  the  juncture  of  the  urethra  and  the  bladder. 

Diagnosis. — The  diagnosis  is  made  by  careful  examination  of  the 
floor  of  the  urethra  by  means  of  a  finger  introduced  into  the  vagina 
and  by  the  passage  of  bulbous  bougies.  By  the  vaginal  touch  cica- 
tricial induration  of  any  part  of  the  urethra,  if  marked,  can  be  found. 
This  is  the  most  reliable  method  of  detecting  the  stricture  of  the 
neck  of  the  bladder,  described  by  Skene,  since  the  narrowing  may  be  sc 
slight  that  a  comparatively  large  instrument  may  pass  through  readily. 

In  passing  the  bulbous  bougie  it  must  be  borne  in  mind  that  the 
urethra  in  women  has  two  points  of  physiological  narrowing, — i.e.,  the 
meatus  and  the  neck  of  the  bladder ;  the  canal  between  these  points 
admits  of  wide  dilatation.  If  a  very  large  bulbous  bougie  is  introduced, 
the  resistance  offered  to  the  inward  or  outward  passage  of  the  instru- 
ment by  the  seats  of  normal  narrowing  might  readily  be  mistaken  for 
that  due  to  organic  stricture. 

Prognosis. — The  prognosis  of  stricture  of  the  urethra  in  women  is 
much  less  serious  than  is  the  case  with  men.  The  narrowing  rarely 
reaches  such  a  degree  that  the  function  of  micturition  is  greatly  in- 
terfered with,  and  hence  the  train  of  vesical,  renal,  and  general  vas- 
cular changes  which  ultimately  result  fatally  is  rarely  inaugurated.  In 
exceptional  cases  when  the  urethral  calibre  is  markedly  encroached  on, 
if  the  condition  is  unrelieved,  the  prognosis  is  the  same  as  for  men. 

Treatment. — Congenital  or  inflammatory  narro wings  of  the  meatus 
should  be  cut  freely,  the  normal  calibre  being  maintained  by  the  use  of  a 
meatus  bougie.  The  directions  given  for  the  performance  of  meatotomy 
in  the  male  obtain  in  these  cases.  Soft,  recent,  dilatable  strictures  are 
gradually  cured  by  short  straight  steel  sounds.  Dense,  traumatic,  nodu- 
lar, irritable,  or  resilient  strictures  are  treated  by  internal  urethrotomy. 
When  the  urethra  is  totally  obliterated  at  one  point  the  propriety  of 
excision  and  of  mucous  membrane  transplantation  may  be  considered. 

17 


CHAPTER   VII.       ' 

URETHRAL  FEVER. FISTULA. — POUCHES. VEGETATIONS. — DISEASES    OF    COW- 

PEr's    GLANDS. URETHROSCOPY. CARE    OF    URETHRAL    INSTRUMENTS. 

Urethral  fever,  called  also  urinary  fever  and  catheter  fever,  is  the 
most  serious  sequel  of  mechanical  interference  v^dth  the  urethra,  and 
is  due  to  absorption  of  bacteria  or  their  poisonous  products  through  a 
hyperaemic  or  abraded  mucous  surface. 

Since  the  passage  of  an  instrument  into  the  urethra  has  been 
shown  to  produce  a  sudden,  sometimes  very  pronounced  fall  of  blood 
pressure,  it  is  not  difficult  to  account  for  the  syncope  so  frequently 
observed  as  a  result  of  even  the  most  gentle  introduction  of  the  sound. 
As  a  direct  or  remote  result  of  this  primary  reflex  influence  on  the 
circulation,  when  the  kidneys  are  already  diseased,  it  is  conceivable 
that  their  secretory  function  may  be  abolished,  and  that  death  may 
result  from  the  ureemia  incident  to  anuria.  Such  cases — i.e.,  those 
characterized  by  syncope,  collapse,  or  anuria,  presenting  all  the  symp- 
toms of  shock  and  exceptionally  terminating  fatally  in  a  very  few 
hours — are  not  properly  classed  under  urethral  fever,  and  should 
receive  the  immediate  stimulating  treatment  appropriate  to  syncope 
or  shock  and  afterwards  that  called  for  in  uraemia. 

There  is,  however,  evidence  that  the  reflex  element,  aside  from 
primary  syncope,  plays  a  minor  role  in  the  development  of  the  phe- 
nomena just  described.  Although  certain  forms  of  urinary  fever  are 
apparently  too  rapid  in  their  course  to  be  ascribed  to  septic  infec- 
tion, Albarran  reports  a  case  of  internal  urethrotomy  in  which  the 
bacterium  coli  commune  was  found  in  the  blood  of  the  patient,  who 
died  twelve  hours  after  operation.  This  same  micro-organism  was  dis- 
covered in  the  urethral  pus.  From  this  and  from  many  similar  cases 
it  would  seem  clear  that  even  though  the  classical  symptoms  of  septic 
absorption  are  absent, — i.e.,  chill,  fever,  and  sweat, — and  though  the 
case  progresses  to  a  fatal  issue  in  a  few  hours,  this  rapid  and  irregular 
course  does  not  necessarily  imply  a  reflex  non-septic  inhibition  of  the 
renal  function.  When  the  kidneys  are  already  crippled,  it  is  possible 
that  even  slight  interference  with  the  urethra  may  arrest  their  action, 
and  as  a  result  death  may  occur  independently  of  sepsis. 

Etiology. — Retention  of  urine,  with  the  consequent  effects  on  the 

258 


TJRETHEAL   FEVER.  259 

bladder  walls  and  the  kidneys, — i.e.,  chronic  cystitis,  pyelitis,  and 
nephritis, — acts  as  a  strong  predisposing  factor  in  the  development  of 
urinary  fever.  As  an  exciting  cause,  contact  of  infected  urine  or  of 
purulent  discharges  with  fissure  or  abrasion  of  the  mucous  membrane 
of  the  urethra  is  sufficient.  Urethral  fever  by  no  means  follows  as  a 
rule  in  consequence  of  such  contact.  It  is  well  known  that  forcible, 
clumsy,  unsuccessful  catheterization,  attended  by  profuse  bleeding  and 
rupture  of  the  urethra,  may  be  followed  by  no  constitutional  symp- 
toms, while  the  most  skilful  and  gentle  introduction  of  an  instrument 
may  cause  a  malignant  form  of  urinary  fever. 

Lesions  situated  behind  stricture  and  seats  of  obstruction,  and 
particularly  lesions  of  the  deep  urethra,  are  more  hable  to  be  followed 
by  urinary  fever  than  are  wounds  so  placed  that  the  septic  fluids  are 
not  driven  into  them. 

It  has  been  noted  frecpently  that  in  cases  where  urinary  fever 
occurred  each  time  a  stricture  was  sounded,  instruments  could  be 
passed  with  impunity  on  complete  cure  of  the  narrowing.  In  some 
cases  no  fever  develops  till  after  the  urine  has  come  in  contact  with 
the  raw  surface  :  thus  it  is  not  uncommon  to  have  a  post-urethrotomy 
urinary  fever  delayed  till  from  the  third  to  the  fifth  day,  when  the  per- 
manent catheter  is  removed,  and  the  urine  is  allowed  to  flow  over 
the  raw  surfaces.  After  perineal  urethrotomy  and  cystotomy,  urinary 
fever  is  extremely  rare. 

The  constitutional  symptoms  incident  to  rapid  extravasation  of 
urine  are  those  characteristic  of  diffuse  cellulitis,  and  are  not  properly 
classed  with  urinary  fever. 

Symptoms. — The  particular  form  in  which  urinary  fever  may  mani- 
fest itself  is  quite  independent  of  the  severity  of  the  exciting  lesion, 
since  in  at  least  one  reported  case,  in  which  death  occurred  a  few 
hours  after  the  passage  of  a  catheter,  no  breach  was  found  in  the  con- 
tinuity of  the  urethral  mucous  membrane.  The  character  of  the  feve^ 
is  probably  dependent  on  the  virulence  of  the  germs  and  on  the  tissue 
resistance  of  the  individual. 

Guyon  classifies  urinary  fever  under  the  general  headings  of  acute 
and  chronic. 

Acute  urinary  fever  may  take  one  of  the  two  following  forms : 
1,  single  paroxysm  ;  2,  recurrent  paroxysms. 

Acute  Urinary  Fever. — Single  Paroxysm. — This  is  characterized 
by  chill,  fever,  and  sweat.  The  chill  may  come  on  a  few  minutes  after 
catheterization  ;  usually  it  follows  the  first  act  of  micturition  subse- 
quent to  urethral  interference.  The  chill  is  pronounced,  the  fever 
high,  103°  to  105°  F.,  the  sweat  copious. 


260  GENITO-UKINAKT  DISEASES  AND   SYPHILIS. 

There  is  a  single  paroxysm,  which  subsides  in  twenty-four  hours : 
at  its  height  there  may  be  pain  in  the  head  and  back,  dehrium, 
dyspnoea,  nausea,  and  vomiting.  Usually  the  pulse  is  full  and  strong, 
the  mind  is  clear,  and  the  patient  feels  comparatively  well. 

This  form  of  urinary  fever  is  the  most  common,  and  when  it  is 
frankly  expressed  is  not  greatly  to  be  dreaded.  If  the  chill  is  severe, 
the  heart  action  modified  out  of  proportion  to  the  amount  of  fever, 
and  the  patient  delirious  and  markedly  dyspnoeic,  the  chances  are 
that  there  will  be  renewed  paroxysms. 

Exceptionally  the  chill  is  unduly  severe  and  prolonged,  lasting 
possibly  for  several  hours ;  the  patient  becomes  collapsed,  vomits, 
purges,  ceases  to  secrete  urine,  and  dies  in  a  few  hours,  or  in  one 
or  two  days,  of  shock,  of  uraemia,  or  of  virulent  septic  poisoning. 

2.  The  form  with  recurrent  paroxysms,  termed  by  Thompson  acute 
recurring  urinary  fever,  is  characterized  by  irregular  and  apparently 
causeless  elevations  in  temperature,  preceded  by  rigors  or  chills, 
which  are  not  so  well  marked  as  in  the  first  attack,  and  are  followed 
by  sweats.  The  temperature  in  the  interim  does  not  reach  normal, 
the  heart  action  continues  unduly  rapid.  These  paroxysms  may  occur 
several  times  a  day,  or  the  intervals  may  be  of  one  to  several  days' 
duration.  Oppression  in  breathing  and  congestion  of  the  lungs  are 
often  noticed.  In  favorable  cases  these  attacks  cease  in  a  few  days  or  a 
Aveek,  and  the  patient  shortly  regains  strength,  though  not  so  rapidly  as 
after  the  single  paroxysm.  When  there  is  a  focus  of  suppuration,  as  in 
cases  of  prostatic  abscess  or  hmited  urinary  extravasation,  septicaemia 
or  pyaemia  may  develop,  with  characteristic  symptoms,  and,  if  the  in- 
fecting focus  is  not  found  and  drained,  usually  with  a  fatal  termination. 

Chronic  Urinary  Fever. — This  may  directly  follow  either  of  the 
preceding  forms,  or  may  develop  insidiously,  at  times  without  elevation 
of  temperature.  Long-standing  retention,  and  the  consequent  changes 
in  the  bladder  and  kidneys,  are  the  common  predisposing  factors. 
The  exciting  factor  is  infection  incident  to  catheterization. 

Symptoms. — The  symptoms  of  this  form  of  urinary  fever  are  septic 
or  uraemic.  Hectic — i.e.,  irregular  paroxysms  of  chills,  fever,  and 
sweat,  with  progressive  loss  of  strength — may  be  combined  with  dry 
brown  tongue,  vomiting,  diarrhoea,  headache,  and  stupor.  This  con- 
dition may  last  for  weeks  without  instrumentation,  but  is  prone  to 
terminate  fatally  on  the  slightest  mechanical  interference  with  the 
bladder  or  the  urethra. 

Prognosis. — Urethral  fever,  when  it  appears  as  a  single  paroxysm 
none  of  the  stages  of  which  are  markedly  severe  or  prolonged,  is  not 
especially  serious.     A  heavy,  prolonged  chill,  especially  if  it  is  asso- 


URETHEAL   FEYER.  261 

ciated  with  a  rapid  pulse-rate  out  of  proportion  to  the  temperature, 
and  with  suppression  of  urine,  always  suggests  a  mahgnant  and  at 
times  a  rapidly  fatal  form  of  infection. 

In  recurrent  paroxysms,  if  the  kidneys  are  healthy  and  the  patient 
is  young,  the  prognosis  is  fairly  good. 

In  chronic  urinary  fever  the  prognosis  must  be  guarded.  Old 
prostatics  who  have  suffered  long  before  being  relieved  usually  die 
when  this  form  of  urinary  fever  develops ;  indeed,  it  is  commonly  a 
sign  of  septic  infection  of  the  kidneys.  In  younger  men  with  retention 
from  stricture  the  prognosis  is  somewhat  more  favorable. 

Treatment. — Rigid  antisepsis,  both  of  instruments  and  of  the 
urethra  and  the  bladder,  is  the  most  potent  means  of  preventing 
urinary  fever.  Before  operating  on  the  urethra  a  preliminary  bacte- 
riological examination  of  the  urine  is  advisable.  If  virulent  colonies 
of  the  colon  group  are  found,  it  is  well  to  postpone  operation  till  these 
have  disappeared  as  a  result  of  internal  and  local  antiseptic  treat- 
ment, or  if  surgical  interference  is  urgently  demanded  this  should  be 
followed  by  perineal  drainage. 

Acute  urinary  fever,  characterized  by  a  single  paroxysm  or  by  re- 
curring paroxysms,  provided  the  urine  is  abundant  and  normal  and 
the  circulation  is  not  materially  disturbed,  requires  only  rest  in  bed, 
the  administration  of  urinary  antiseptics,  a  bland  liquid  diet,  preferably 
milk,  and  a  mild  saline,  Hunyadi  or  magnesium  sulphate,  in  sufficient 
doses  to  cause  three  loose  passages  a  day.  When  the  constitutional 
symptoms  are  well  marked,  the  pulse  becoming  progressively  more 
rapid  and  feeble,  stimulants  and  tonics  are  indicated,  much  the  same 
treatment  being  pursued  as  for  septicaemia.  Should  the  urine  become 
loaded  with  albumen  or  contain  blood,  or  should  the  kidneys  cease 
to  secrete,  dry  cups  over  the  loins,  a  half-dozen  to  each  side,  followed 
by  a  digitalis  poultice,  full  doses  of  tincture  of  digitalis,  a  teaspoonful 
thrice  daily  (Otis),  and  on  the  supervention  of  uraemic  symptoms  the 
hot  vapor  bath,  repeated  according  to  the  indications,  are  the  measures 
which  promise  best  results. 

When  in  spite  of  careful  local  and  general  treatment  symptoms 
of  septic  absorption  are  steadily  progressive,  perineal  drainage  should 
be  established,  supplemented  by  copious  urethral  and  vesical  irriga- 
tions. This  operation — indeed,  any  interference  with  the  urethra — is, 
in  the  case  of  those  who  have  long  suffered  from  retention  of  urine 
to  which  has  been  superadded  urinary  fever,  so  often  followed  by 
an  aggravation  of  constitutional  symptoms  that  there  is  a  natural, 
reluctance  on  the  part  of  surgeons  to  operate.  Under  the  circum- 
stances, however,  such   interference   practically  holds   out  the  only 


262  GEXITO-UEIXAKY   DISEASES    AXD    SYPHILIS. 

hope.     If  the  organism  has  already  received  a  fatal  dose  of  the  germs 

or  their  products,  or  if  the  kidneys  are  hopelessly  disorganized,  the 
operation  can  at  the  worst  merely  hasten  the  inevitable  fatal  ter- 
mination. If  the  infection  is  progressive  because  of  constant  fresh 
absorption  from  the  urethra,  perineal  drainage  may  be  as  serviceable 
as  is  opening  an  abscess  in  a  case  of  ordinary-  suppuration. 

FISTULA   OF   THE   URETHRA. 

Fistula  of  the  urethra  is  an  abnormal  opening  through  which  the 
urine  escapes  from  this  canal,  either  into  the  rectum  or  externally. 
Very  exceptionally  these  flstulae  are  congenital,  and  are  due  to  the 

estabhshment  of  the  function  of  the  kidney  before  the  urethral  canal 
is  fully  formed.  The  bladder  becomes  overdistended.  and  the  urethra, 
not  being  pervious,  ruptures  at  a  point  behind  the  obstruction,  thus 
rehe^^ng  tension  and  allowing  the  urine  to  escapt-. 

The  usual  cause  of  urethral  fistula  is  slow  leakage  of  urine  incident 
to  ulceration  behind  a  stricture,  though  suppurative  follicuhtis  and 
periurethral  abscess  occurring  in  the  course  of  acute  or  chronic  gonor-. 
rhoea,  the  lodgement  of  a  stone  or  of  a  foreign  body,  or  rupture  or 
wound  of  the  urethra  may  result  in  fistula  formation. 

In  accordance  with  the  position  of  the  opening  and  course  of  the 
tract  the  fistula  is  named  urethro-rectal.  urethro-perineo-scrotal.  or 
urethro-penile. 

Urethro-rectal  fistula,  in  the  non-congenital  varieties,  formerly 
were  usually  due  to  injury  inflicted  during  the  perineal  operation  for 
stone,  the  rectum  being  accidentally  wounded. 

The  common  cause  at  the  present  time  is  the  slow  backward  ex- 
tension of  prostatic  abscess,  the  ulceration  ultimately  reaching  and 
destroying  the  rectal  wall,  and  forming  a  small  opening,  except  in 
cases  of  acute  inflammation.  Tubercular  or  mahgnant  infiltration, 
whether  primary  in  the  urethra  or  in  the  rect^un,  often  causes  the 
tissues  lying  between  to  break  down. 

Finally,  a  foreign  body  or  calculus  long  retained  in  the  prostatic 
urethra  may  produce  urethro-rectal  fistula.  In  such  cases  the 
urethral  opening  is  usually  small,  and  is  generally  in  the  prostatic 
portion  of  the  canal,  at  the  side  of  the  verumontanmn,  the  course 
of  the  fistula  being  obUquely  downward  and  backward :  hence  there 
is  less  chance  of  faeces  passing  into  the  urethra  than  of  the  urine 
flowing  into  the  rectum.  In  addition  to  the  recta]  opening  there  is 
often  a  tract  opening  into  the  perineum.  Other  tracts  may  form, 
passing  back  to  the  perinemn  and  to  the  ischio-rectal  region,  or  through 
the  great  sacro-sciatic  foramen  opening  near  the  hip-joint,  or  upward 


URETHRAL    FISTULA.  263 

on  the  belly-wali.  The  main  tract,  starting  from  a  prostatic,  or  peri- 
prostatic abscess-cavity,  has  often  many  diverticula,  forming  blind 
suppurating  sinuses. 

The  fistulous  tract  forms  a  dense,  cord-like  band,  easily  felt  on 
rectal  examination,  when  there  is  not  much  infiltration  of  surrounding 
tissues.  The  opening  into  the  rectum  is  placed  within  the  sphincter, 
and  may  be  so  small  and  so  well  covered  by  rectal  folds  that  the  find- 
ing of  it  will  be  difficult ;  in  malignant  and  tubercular  cases  it  is 
marked  by  a  button  of  exuberant  granulations.  Following  large, 
rapidly  exteiiding  abscess  of  the  prostate  there  is  decided  loss  of  sub- 
stance, the  opening  then  being  of  consideralDle  size.  The  contact  of 
the  urine  often  produces  an  inflammatory  condition  not  only  of  the 
rectal  mucous  membrane  but  also  of  the  skin  surrounding  the  anus. 

Symptoms. — Pathognomonic  symptoms  of  urethro-rectal  fistula  are 
the  passage  of  urine  by  the  rectum  and  the  escape  of  gas  and  excep- 
tionally of  faeces  through  the  urethra. 

The  quantity  of  urine  passing  into  the  rectum  varies  in  accordance 
with  the  size  of  the  fistula.  When  the  urethra  is  not  obstructed,  but 
a  few  drops  escape  in  this  direction.  These  usually  appear  externahy 
during  or  immediately  after  urination,  though  sometimes  the  urine  is 
retained  and  is  discharged  by  the  motions  of  defecation,  exactly  as 
would  be  a  hcjuid  stool.  Gas  and  fa?ces  may  escape  from  the  urethra 
either  during  or  after  defecation. 

On  rectal  examination  the  nodular  induration  characteristic  ot  a 
iBstula  is  easily  detected.  By  means  of  a  speculum  the  opening  of  this 
tract  can  be  found  and  a  probe  can  be  passed  through  it,  encountering 
the  end  of  a  sound  passed  through  the  urethra  and  into  the  bladder. 
The  urethral  orifice  can  sometimes  be  detected  by  urethroscopic 
examination,  and  positive  diagnosis  may  be  made  by  forcing  a  colored 
liquid,  such  as  one-tenth  per  cent,  methyl-blue  solution  into  the  uretlira. 
and  noting  whether  or  not  it  can  be  seen  in  the  rectum.  Or  equally 
decisive  is  the  injection  of  hydrogen  peroxide  into  the  rectal  opening 
of  the  fistula,  the  bubbles  due  to  oxidation  then  appearing  in  the  urine. 

Diagnosis. — The  differential  diagnosis  of  urethro-rectal  from  vesico- 
rectal fistula  is  made  by  cystoscopic  examination  and  by  injection 
of  colored  fluids  in  moderate  quantity  directly  into  the  bladder  with 
the  patient  in  the  dorsal  decubitus.  If  the  fistulous  opening  be  in 
the  urethra,  this  solution  will  not  appear  in  the  rectum  till  the  patient 
urinates.  In  urethro-rectal  fistula  urine  usually  escapes  only  during 
the  act  of  micturition,  and  the  inflammation  of  both  the  rectum  and 
the  bladder  is  much  less  marked  than  when  the  opening  is  directly 
into  the  latter  viscus. 


264  GEIs^ITO-UKIXAET   DISEASES   AJs^D   SYPHILIS. 

A  tubercular  urethro-rectal  fistula  would  be  found  associated  with 
an  irregularly  nodulated  prostate,  probably  an  infiltration  and  nodu- 
lation  of  one  or  both  seminal  yesicles,  with  great  thickening  of  the 
tissue  lying  between  these  two  pouches,  often  induration  and  enlarge- 
ment of  the  epididymis,  and  the  presence  of  tubercular  cystitis  and 
tubercle  bacilli  in  the  urine.  Urethro-rectal  fistula  occurs  in  malig- 
nant disease  only  when  the  infiltration  is  so  well  marked  as  to  be 
practically  unmistakable. 

Prognom. — The  prognosis  of  urethro-rectal  fistula  in  tubercular 
and  cancerous  cases  is  hopeless ;  even  in  simple  ulceration,  if  there 
has  been  much  destruction  of  tissue,  the  chances  of  ultimate  cure  are 
extremely  slight.  If  the  fistula  is  small  it  may  heal  spontaneously, 
especially  after  the  relief  of  urethral  obstruction,  which  has  tended 
to  keep  it  open.  The  consequences  of  an  uncured  fistula  of  this 
kind  are  usually  grave,  since  both  the  rectum  and  the  bladder  become 
chronically  inflamed,  and  are  subject  to  the  immediate  and  remote 
complications  incident  to  such  inflammation. 

Treatment. — Spontaneous  cure  may  take  place  after  fistula-forma- 
tion resulting  from  suppuration  of  a  prostatic  gland.  This  is  rare. 
One  case  was  cured  by  directing  the  patient  to  urinate  only  when  in 
the  position  of  ventral  decubitus.  The  most  important  point  in  treat- 
ment is  to  remove  obstruction  from  the  urethra.  Although  stricture 
is  not  a  common  cause  of  this  form  of  fistula,  when  once  the  abnormal 
opening  is  formed  a  very  slight  urethral  narrowing  may  be  sufficient  to 
keep  it  open  indefinitely. 

If  restoration  of  the  urethral  canal  to  its  normal  calibre  is  not 
followed  by  cure  of  the  fistula,  the  tract  of  the  latter  should  be  pro- 
tected from  the  irritation  incident  to  the  passage  of  urine  and  fasces 
by  regular  catheterization,  or,  better  still,  continuous  catheterization 
kept  up  for  several  weeks,  and  by  the  checking  of  diarrhoea  and  over- 
stretching of  the  rectal  sphincter.  Perineal  and  ischio-rectal  tracts, 
together  with  their  diverticula,  should  be  opened,  curetted,  and 
forced  to  heal  from  the  bottom  by  packing. 

Duplay  advises  the  introduction  into  the  rectum  of  a  silver  canula 
furnished  with  an  apron  for  the  purpose  of  closing  the  fistulous 
orifice  in  the  intervals  of  defecation. 

The  fistula  still  remaining  open,  repeated  cauterizations  of  the 
rectal  orifice  and  of  the  whole  tract  by  a  stick  of  copper  sulphate  or- 
silver  nitrate,  or  by  the  galvano-cautery,  may  be  tried,  bui  will  suc- 
ceed only  in  case  the  suppurating  canal  is  very  small. 

These  means  having  failed,  a  staff  is  passed  into  the  bladder,  and 
a  probe  is  introduced  into  the  rectum  until  it  comes  in  contact  with 


URETHRAL   FISTULA.  265 

this  staff.  External  perineal  urethrotomy  is  then  performed,  open- 
ing the  urethra  at  the  point  where  the  fistula  begins.  The  perineal 
incision  is  continued  in  such  a  way  that  the  fistulous  tract  passing 
through  the  recto-vesical  septum  is  cut  transversely.  The  callous 
walls  of  the  fistula  are  then  thoroughly  curetted,  a  permanent  drain- 
age-tube is  passed  from  the  perineum  into  the  bladder,  and  the 
portion  of  the  incision  bisecting  the  fistulous  tract  is  well  packed 
with  iodoform  gauze.  As  a  result  of  this  operation  the  urine  is 
diverted  from  its  course  before  it  reaches  the  rectal  opening,  and  the 
latter  frequently  heals.  The  operation  is  sometimes  successful  in 
closing  both  the  urethral  and  the  rectal  opening.  In  case  one  closes 
and  the  other  remains,  the  operation  appropriate  to  simple  fistula  will 
probably  be  successful. 

A  more  radical  method  of  procedure,  and  one  giving  a  better  pros- 
pect of  success,  is  thus  conducted.  A  curved  incision  is  made  across 
the  perineum  in  front  of  the  anus,  this  orifice  lying  in  the  concavity  of 
the  curve.  This  incision,  identical  with  that  employed  for  exposing  the 
seminal  vesicles,  is  deepened  till  the  rectal  and  urethral  orifices  of  the 
fistula  are  exposed  and  made  accessible.  In  this  dissection  a  finger 
introduced  into  the  bowel  and  a  sound  passed  through  the  urethra 
into  the  bladder  will  enable  the  surgeon  to  avoid  wounding  either  the 
rectum  or  the  urethra.  The  two  orifices  having  been  exposed,  and 
the  main  tract  and  its  diverticula  having  been  opened,  thoroughly 
curetted,  and  cleaned,  the  edges  of  each  fistulous  opening  are  exten- 
sively denuded  and  closed  by  catgut  suture  introduced  as  in  the 
closing  of  vesico-vaginal  fistula.  When  the  tract  is  small  and  fairly 
direct  and  the  surrounding  tissues  are  healthy,  the  perineal  wound 
may  be  closed  by  buried  catgut  sutures.  When  there  have  been 
much  infiltration  and  suppuration,  the  wound  should  be  packed  and 
allowed  to  heal  from  the  bottom. 

In  fistula  dependent  upon  malignant  disease  such  operations  are 
not  to  be  considered. 

Urethro-Perineo-Scrotal  Fistula. — This  fistula,  by  far  the 
commonest  of  all,  is  usually  due  to  ulceration  behind  a  stricture, 
though  traumatism,  erosion  by  stone  or  foreign  body,  acute  abscess, 
ulceration  extending  from  caries  or  necrosis  of  the  pelvis,  or  tuber- 
cular or  gummatous  infiltration,  may  occasionally  cause  it.  The 
urethral  orifice  is  generally  single,  but  externally  there  may  be  several 
openings ;  this  being  due  to  the  fact  that  the  one  first  formed  has  a 
tendency  to  contract  slowly,  thus  obstructing  the  flow  of  urine,  which 
then  burrows  in  various  directions.  In  cases  of  urinary  extravasation 
from  traumatism  several  fistulae  may  be  formed  at  the  same  time. 


266  GENITO-URINARY  DISEASES  AND   SYPHILIS. 

Occasionally  the  cutaneous  orifices  of  the  fistula  are  placed  well 
back  on  the  buttocks,  down  the  thighs,  in  the  region  of  the  hip,  or  in  the 
belly  wall,  though  usually  they  are  found  in  the  perineum  and  scro- 
tum. These  fistulse  form  dense  fibrous  tracts  easily  detected  on 
palpation.  Some  of  these  tracts  end  in  blind  pouches,  others  open 
externally.  They  are  lined  by  unhealthy  granulations,  sometimes, 
though  rarely,  by  epithelium.  Occasionally  in  their  interior  calculi 
are  formed,  or  their  walls  are  incrusted  with  urinary  salts.  The 
skin  and  subcutaneous  tissue  of  the  scrotum  and  perineum  are  often 
enormously  thickened,  producing  a  condition  much  like  elephantiasis. 
About  the  fistulous  orifices  large  fibrous  nodules  of  partially  organized 
inflammatory  tissue  may  form. 

Diagnosis. — The  diagnosis  is  made  easily.  Pus  and  urine  escape 
from  the  surface  openings  of  the  fistula,  the  skin  of  the  perineum  and 
scrotum  is  inflamed  and  thickened,  and  the  indurated  tracts  charac- 
teristic of  fistula  are  detected  on  palpation. 

Frequently  urine  escapes  from  the  opening  in  very  small  quantity 
and  acute  inflammatory  phenomena  are  entirely  wanting.  Under 
these  circumstances  blocking  the  urinary  meatus  during  micturition 
may  cause  a  few  drops  of  urine  to  escape  externally,  or  careful  probing 
through  the  fistula,  a  steel  instrument  having  been  passed  into  the 
urethra,  may  determine  whether  or  not  the  skin  sinus  communicates 
with  this  mucous  channel. 

Finally,  the  use  of  colored  injections,  or  of  hydrogen  peroxide,  or 
of  the  urethroscope,  may  be  necessary  before  diagnosis  can  be  made. 

The  differential  diagnosis  between  urethro-perineal  and  perineo- 
anal  fistula  is  founded  on  the  history  of  the  case ;  in  the  former  in- 
stance there  is  usually  a  history  of  stricture,  or  at  least  of  dysuria, 
foflowed  by  perineal  abscess  and  escape  of  urine.  Probing  generally 
determines  definitely  the  character  of  the  fistula.  The  course  taken 
by  hydrogen  peroxide  or  methyl-blue  solution  injected  into  the  ex- 
ternal opening  under  pressure  will  also  usually  settle  the  matter 
positively.  Exceptionally  it  will  show  an  opening  into  both  the 
urethra  and  the  rectum.  Finally,  in  the  case  of  anal  and  rectal 
fistulse  examination  conducted  with  a  good  head  light  and  a  spec- 
ulum, the  patient  being  in  the  knee-chest  position,  will  nearly  always 
show  the  opening  into  the  bowels. 

Through  perineo-scrotal  sinuses  kept  open  by  caries  of  the  pelvic 
bones  there  is  no  escape  of  urine.  Moreover,  by  careful  probing  the 
roughened  bone  often  can  be  felt. 

Sinuses  dependent  upon  chronic  suppuration  of  Cowper's  glands 
or  of  the  urethral  glands  can  be  diagnosed  from  fistulas  onlv  bv  the 


URETHRAL   FISTULA.  267 

absence  of  urine  leakage  and  the  negative  results  of  pressure  in- 
jections. 

Treatment. — The  formation  of  these  fistulse  may  be  prevented  by 
prompt  suture  of  the  urethra  in  case  the  canal  is  ruptured  or  wounded 
either  surgically  or  accidentally ;  by  the  immediate  evacuation  and 
packing  of  glandular  and  periglandular  urethral  abscesses,  followed 
by  continuous  catheterization  ;  and  by  the  immediate  dilatation  of 
strictures  as  soon  as  they  begin  to  give  obstructive  symptoms. 

A  perineo-scrotal  fistula  having  formed,  complete  restoration  of  the 
urethra  to  its  normal  calibre  is  the  first  essential  in  successful  treat- 
ment. The  partial  cure  of  stricture  is  in  these  cases  unavailing. 
Usually  when  the  calibre  of  the  urethra  is  carried  up  to  the  point  in- 
dicated in  the  scale  given  on  page  220,  the  fistula,  unless  its  walls  are 
too  densely  indurated  or  have  been  covered  with  pavement  epithelium, 
will  heal  spontaneously.  At  times  continuous  catheterization,  supple- 
mented by  cleansing  and  stimulating  the  fistulous  tracts,  will  accom- 
plish a  cure. 

Since  this  variety  of  fistula,  or  at  least  its  most  intractable  form,  is 
rarely  found  except  in  conjunction  with  stricture  at  or  about  the 
bulbo-membranous  juncture,  it  is  advisable  to  restore  the  urethral 
calibre  by  external  urethrotomy,  employing  continuous  catheterization 
afterwards  possibly  for  two  or  three  weeks.  This  not  only  cures  the 
stricture,  but  entirely  diverts  the  urine  from  the  fistulous  tracts,  thus 
giving  them  an  opportunity  to  heal.  If  the  latter  are  densely  indu- 
rated, or  crusted  with  the  salts  of  urine,  they  should  be  laid  open  freely 
through  their  entire  course,  curetted,  and  packed  with  iodoform  gauze, 
and  allowed  to  heal  from  the  bottom.  Fibrous  nodules,  especially 
those  placed  about  the  urethra  and  in  the  skin  openings  of  the  tracts, 
should  be  excised. 

Urethro-penile  fistula  is  usually  encountered  as  a  short,  straight, 
single,  non-indurated  channel,  lined  with  pavement  epithehum,  pass- 
ing by  the  shortest  route  from  the  urethra  to  the  surface,  though 
exceptionally,  when  the  urinary  extravasation  has  taken  place  from 
the  mid-penile  portion  of  the  urethra,  it  may  form  a  subcutaneous 
tract,  running  parallel  with  the  course  of  the  urethra  and  opening  just 
behind  the  glans.  Or  the  fistulous  tract  may  pass  backward  and  open 
near  the  root  of  the  penis. 

Treatment. — The  restoration  of  the  normal  calibre  of  the  urethra 
anterior  to  the  fistula  is  the  first  essential  of  treatment,  and  will  often 
be  curative. 

If  the  fistula  persists,  regular  evacuation  of  the  bladder  by  means 
of  a  catheter  should  be  continued  for  a  week,  the  urethra  receiving 


268 


GENITO-UEINAEY   DISEASES  AND   SYPHILIS. 


Fig.  94. 


an  antiseptic  flushing  (boric  acid  four  per  cent.,  or  silver  nitrate  1  to 
1000)  after  each  passage  of  the  instrument.  If  this  fails,  and  if  the 
fistula  is  direct  and  of  small  size,  cauterization  of  the  tract  by  the 
galvano-cautery  may  cure.  This  failing,  the  urethra  should  be  thor- 
oughly freed  about  the  margins  of  the  opening,  and  the  borders  of 
the  latter  having  been  freshened  should  be  ap- 
proximated by  a  rov^  of  catgut  sutures  (Fig.  94) ; 
another  row  of  silk  sutures  is  employed  to  bring 
together  the  skin  and  underlying  fascia.  The 
dilating  speculum  or  urethral  dilator  greatly 
facihtates  this  operation.  Undue  tension  on  the 
sutures  and  contamination  by  urine  may  be  pre- 
vented by  regular  catheterization,  or  still  more 
surely  by  perineal  urethrotomy,  the  bladder 
being  drained  through  this  opening  till  the  fistula 
is  permanently  closed. 

If  the  fistula  is  so  large  that  closure  by  this 
operation  would  entail  too  great  an  encroach- 
ment on  the  urethral  calibre,  a  plastic  operation 
will  be  rec{uired.  A  transplanted  flap  is  usually 
taken  from  the  scrotum ;  or  one  from  the  pre- 
puce or  from  the  inguinal  or  abdominal  region 
may  be  employed.  When  the  flap  is  taken  from 
the  scrotum,  a  quadrilateral  space  about  the  fistulous  opening  is 
freshened,  a  flap  of  similar  shape,  with  its  adherent  base  down,  is 
raised  from  the  scrotum,  and  its  anterior  and  lateral  borders  are 
sutured  to  the  freshened  surfaces.  In  a  week  the  pedicle  is  divided 
and  secured  to  the  posterior  border  of  the  defect.  To  secure  success 
in  these  cases,  regular  catheterization  or  perineal  urethrotomy  is 
necessary. 

Probably  the  most  efficient  way  of  closing  these  fistulse  is  by  the 
operation  of  double  lateral  flaps  described  as  appropriate  to  the  treat- 
ment of  hypospadia.  (See  page  79.)  The  short  flaps  are  turned  in, 
bringing  the  skin  surfaces  towards  the  urethra ;  then  the  long  flaps, 
so  freely  dissected  that  they  are  subject  to  very  little  tension,  are 
brought  together  by  sutures,  their  raw  surfaces  being  apposed  to  the 
raw  surfaces  of  the  inverted  short  flaps. 


Closure  of  fistula. 


URETHRAL   POUCHES. 

In  addition  to  the  congenital  pouches  already  described,  there  are 
observed  sacculations  at  the  expense  of  the  urethral  wall,  due  either 
to  gradual  yielding  to  vesical  pressure  or,  more  commonly,  to  ulcera- 


URETHKAL   NEOPLASMS.  269 

tion  and  abscess-formation,  or  to  both  these  causes  combined.  The 
predisposing  factor  is  inflammation  incident  to  stricture,  especially 
when  there  is  a  calculus  lodged  behind  the  stricture. 

Symptoms. — The  symptoms  are  sufficiently  characteristic.  There 
is  long-continued  dribbling  of  urine  after  apparent  complete  evacu- 
ation of  the  bladder.  Examination  shows  either  a  sacculation  or  a 
dilatation  in  the  course  of  the  urethra,  which  is  distended  during 
the  course  of  micturition,  and  which  on  being  compressed  becomes 
flaccid,  urine  at  the  same  time  dribbling  from  the  meatus.  In  some 
cases,  when  the  pouch  contains  a  calculus,  the  latter  changes  position 
during  urination,  acting  as  a  valve.  Usually  there  are  no  inflam- 
matory phenomena,  and  the  tumor  is  compressible  and  painless,  thus 
differing  from  chronic  urinary  abscess. 

Treatment. — Treatment  consists  in  extracting  the  calculus,  if  there 
is  one,  either  by  intra-urethral  manipulations  or  by  external  incision. 
Strictures  should  be  cured  by  gradual  dilatation,  or  by  urethrotomy, 
with  perineal  resection  of  the  sac-walls  if  necessary.  Simple  diver- 
ticula behind  the  stricture  are  usually  cured  by  wide  dilatation.  Ex- 
ceptionally after  cure  of  stricture  the  walls  of  the  pouch  must  be 
resected  and  the  opening  into  the  urethra  freshened  and  closed  by 
suture. 

URETHRAL  NEOPLASMS. 

Papillomata  (which  the  urethroscope  has  shown  to  be  not  so 
rare  as  was  believed)  appear  as  pedunculated  or  sessile,  vascular, 
papillary  outcroppings  (Fig.  95),  or  as  true  polyps.  They  grow 
from  any  portion  of  the  canal,  but  are  commonly  found  in  the  na- 
vicular fossa  and  behind  strictured  portions  of  the  urethra,  spring- 
ing from  the  floor.  They  are  usually  small,  but  exceptionally  may 
attain  a  size  sufficient  to  obstruct  very  considerably  the  stream  of 
urine. 

When  they  develop  near  the  meatus,  and  this  is  their  commonest 
seat,  they  are  prone  to  grow  outward,  projecting  from  the  urethral 
orifice  as  a  soft,  easily  bleeding,  fungating  mass. 

Symptoms. — These  are  usually  slight,  and  are  mostly  mistaken  for 
those  of  gleet  dependent  upon  stricture.  There  is  a  thin,  muco-puru- 
lent  discharge,  with  slight  burning  during  urination,  and,  if  the  polyp 
attains  large  size,  interference  with  the  volume  and  force  of  the 
stream.  Often  there  is  free  bleeding  on  instrumentation,  particularly 
in  cases  characterized  by  comparatively  large  areas  of  sessile,  highly 
vascular  papillary  hypertrophy.  The  diagnosis  is  founded  on  an 
intra-urethral  examination.     The  urethroscope  shows  these  growths 


270 


GENITO-URINAEY   DISEASES  AND  SYPHILIS. 


usually   as   slight  villous  projections,  sometimes   as   raspberry-like 
masses,  occasionally  as  gelatinous  pyriform  tumors. 


Fig.  95. 


Papilloma  of  the  urethra.    6,  side  view  of  the  growth.     ( Vcjillemier. 


Treatment. — This  consists  in  removal  of  the  growth  by  means  of  a 
wire  snare,  or  curette,  or  galvano-cautery,  introduced  through  the  ep- 
doscopic  tube.  If  the  polyp  is  snared  or  scraped  away,  the  place  from 
which  it  was  removed  should  be  touched  with  glacial  acetic  acid  or 
pure  carbolic  acid.  This  operation  is  not  difficult  when  the  growths, 
as  is  usually  the  case,  are  situated  near  the  meatus.  A  dilating  specu- 
lum in  these  cases  will  prove  more  serviceable  than  the  closed  tube. 
When  the  growths  are  deep,  great  difficulty  may  be  experienced  in 
their  removal. 

Urethral  caruncles  are  rare  in  the  male  urethra,  but  are  occa- 
sionally found  near  the  orifice  in  the  navicular  fossa. 

They  consist  of  small,  bright,  red,  pedunculated,  highly-vascular, 
papillated  tumors,  made  up  of  connective  tissue,  covered  by  stratified 
epithelium. 

They  are  characterized  by  severe  pain,  aggravated  by  urination, 
and  moderate  muco-purulent,  often  blood-stained,  discharge.  The 
pain  during  sexual  intercourse  is  so  great  as  to  be  inhibitory.  Instru- 
mentation is  intolerable. 

They  are  distinguished  from  irritable  gonorrhoea  by  the  gradual 
onset,  independently  of  intercourse,  and  by  the  absence  of  gonococci 
from  the  discharge.     The  urethroscope  will  disclose  the  tumor. 

The  treatment  consists  of  the  complete  removal  of  the  little  tumor 


DISEASES   OF   COWPEE'S   GLANDS.  271 

— including  its  base — ^by  means  of  small  scissors,  the  wire  ecraseur, 
or  cautery  knife.  A  meatus  dilator  will  usually  make  the  growth 
accessible,  though  a  preliminary  meatotomy  may  be  needful. 

DISEASES  OF  COWPER'S  GLANDS. 

On  either  side  of  the  membranous  urethra,  between  the  two  layers 
of  the  triangular  ligament,  is  placed  a  pea-sized,  lobulated,  racemose 
gland,  the  duct  of  which,  one  inch  long,  perforates  the  anterior  layer 
of  the  triangular  ligament  and  empties  into  the  bulbar  urethra.  These 
glands  are  sexual  in  function,  and  their  secretion  forms  a  part  of  the 
semen.  Both  they  and  their  ducts,  being  lined  by  columnar  epithelium, 
are  readily  susceptible  to  gonorrhoea!  invasion,  and  once  having  been 
infected  remain  fruitful  sources  of  reinfection  after  an  apparently  cured 
urethritis.  These  structures  cannot  be  reached  by  intra-urethral  appli- 
cations, nor  are  they  amenable,  because  of  their  position,  to  massage. 
Chronic  hypersecretion  of  Cowper's  glands  is  a  common  source  of 
intractable  urethrorrhoea.  As  is  the  case  with  their  homologues 
(Bartholin's  glands),  these  structures  are  rarely  infected  by  organ- 
isms other  than  the  gonococcus. 

Cowperitis. — Cowperitis,  or  inflammation  of  Cowper's  gland, 
usually  develops  in  the  third  or  fourth  week  of  an  acute  urethritis. 
It  is  due  to  an  extension  of  the  disease  from  the  bulbous  urethra,  into 
which  the  ducts  of  these  glands  empty.  All  the  causes  which  tend  to 
aggravate  an  attack  of  acute  urethritis,  such  as  sexual  or  alcohoUc 
excesses  or  violent  exercise,  predispose  to  inflammation  of  Cowpers 
gland. 

Symptoms. — The  first  symptom  is  a  sticking  pain  in  the  perineum  ; 
this  is  greatly  increased  by  pressure,  so  that  sitting  or  walking  mark- 
edly increases  the  suffering.  The  swelling  of  the  glands  is  resisted  by 
the  two  layers  of  the  triangular  ligament  between  which  they  are  situ- 
ated and  by  the  deep  perineal  fascia :  hence,  as  the  inflammation 
progresses,  there  is  developed  great  tension. 

Both  micturition  and  defecation  are  painful,  tlie  suffering  being 
particularly  severe  at  the  termination  of  the  former  act,  since  tlie 
transverse  fibres  of  the  compressor  urethras  muscle,  as  they  contract 
to  expel  the  last  drops  of  urine,  conipress  the  inflamed  and  swollen 
gland.  If  the  swelling  is  very  marked  there  will  be  some  difficulty 
in  micturition  from  mechanical  pressure. 

Usually  but  one  gland  is  involved.  It  may  then  be  felt  as  a  small, 
hard,  very  tender  tumor  situated  just  behind  the  bulb, — that  is,  about 
the  middle  of  the  perineum.  This  tumor  may  be  recognized  by  deep 
palpation  of  the  perineum,  or  by  pressure  made  in  an  upward  and  for- 


272  GENITO-UKINAEY   DISEASES  AND  SYPHILIS. 

ward  direction  by  a  finger  inserted  just  within  the  external  sphincter. 
The  fact  that  this  swelhng  is  on  one  side  of  the  median  line  constitutes 
a  distinct  diagnostic  point.  When  both  glands  are  involved  the 
swelhng  will,  of  course,  be  bilateral. 

Suppuration  sometimes  occurs.  When  this  involves  the  peri- 
glandular tissues  the  skin  will  become  reddened  and  oedematous,  and 
the  rigors,  fever,  and  throbbing  pains  of  pus-formation  will  be  present. 
The  swelhng  in  these  cases  is  nearly  always  sufficient  to  interfere 
materially  with  micturition.  The  abscess  usually  perforates  exter- 
nally, and  on  the  discharge  of  a  large  quantity  of  pus  heals  kindly, 
although  it  may  subsequently  be  followed  by  troublesome  cicatricial 
contraction.  In  rare  instances  the  abscess  may  perforate  into  the 
urethra,  but  even  then  extravasation  of  urine  is  very  exceptional. 
The  inflammation  frequently  becomes  chronic,  lingering  particularly 
in  the  gland  ducts,  and  occasioning  a  discharge  which  is  extremely 
hard  to  cure. 

During  the  course  of  an  acute  cowperitis  the  discharge  of  the  ante- 
rior urethritis  usually  ceases  or  is  greatly  diminished  in  quantity. 

Diagnosis. — When  the  case  is  seen  early  the  anatomical  position 
of  the  firm  nodule  or  nodules  renders  diagnosis  easy ;  but  when  sup- 
puration occurs,  together  with  wide-spread  periadenitis,  it  is  sometimes 
hard  to  determine  the  true  nature  of  the  inflammation. 

It  may  be  distinguished  from  a  simple  abscess  of  the  perineum  by 
the  fact  that  the  latter  from  its  position  cannot  cause  compression  of 
the  bulb,  and  therefore  difficult  micturition. 

From  urinary  infiltration  following  stricture  it  can  be  distinguished 
only  by  the  history  of  the  case.  Periurethral  abscess  of  the  bulb  is 
farther  forward  than  is  the  tumor  in  cowperitis,  and  is  always  in  the 
median  line. 

Ti-eatment. — Every  effort  should  be  made  to  lessen  the  urethral 
inflammation.  Strong  antiseptic  or  astringent  injections  or  intra- 
urethral  manipulation  must  be  discontinued  at  once.  Rest  in  bed, 
prolonged  hot  baths,  and  the  administration  of  a  laxative  or  a  saline 
purge  are  always  indicated.  A  hot-water  bag  applied  to  the  perineum 
relieves  pain  and  seems  to  lessen  the  tendency  to  abscess-formation. 
When  the  suffering  is  intense,  hypodermics  of  morphine  driven  into 
the  perineum  are  indicated. 

When  throbbing  pain,  oedema,  fluctuation,  and  rigors  and  fever 
show  that  pus  has  formed,  the  abscess  should  be  cut  into  at  once, 
and  its  cavity  curetted  and  packed  with  iodoform  -gauze.  Urinary 
extravasation,  of  course,  demands  immediate  incision  and  drainage. 
Fistulse  may  be  guarded  against  by  permanent  catheterization  after 


UKETHEOSCOPY.  273 

the  abscess  has  been  opened  and  drained.  When,  in  spite  of  every 
precaution,  fistulse  form,  and  are  not  relieved  by  catheterization  and 
free  dilatation,  excision  of  the  fistulous  tract,  as  well  as  of  any 
remnant  of  the  gland,  and  suture  of  the  freshened  edges,  are  re- 
quired. 

Cysts  of  Cowper's  Glands. — Very  few  cases  have  been  re- 
ported of  cysts  of  the  ducts  of  Cowper's  glands.  These  usually 
form  small  tumors,  projecting  into  the  urethral  lumen  at  the  expense 
of  its  floor.  If  large,  they  may  be  detected  by  perineal  or  rectal 
palpation.  In  one  case  the  tumor  opened  externally,  discharging  a 
viscid  fluid  at  irregular  intervals  ;  this  fluid  was  apparently  secreted 
much  more  rapidly  during  coitus  than  at  other  times. 

Cancer  of  Cowper's  Glands. — Very  few  cases  of  this  affection 
have  been  reported.  The  growth  usually  appears  in  the  form  of  a 
cylindroma,  forming  a  hard,  movable,  distinct  encapsulated  nodule. 
As  it  grows  it  becomes  adherent  to  the  surrounding  parts.  The 
inguinal  glands  are  involved.  The  growth,  at  first  painless  and  attract- 
ing little  attention,  rapidly  increases  in  size  and  ultimately  presses 
upon  the  urethra.  Micturition  becomes  difficult,  frequent,  and  some- 
times painful.  Defecation  is  interfered  with,  and  sitting  or  walking 
increases  suffering. 

Diagnosis.— The  characteristic  feature  of  this  affection  is  the  posi- 
tion of  the  tumor.  It  is  placed  upon  the  bulb,  is  at  first  covered  with 
healthy  skin,  and  grows  rapidly.  Combined  rectal  and  perineal  ex- 
amination shows  it  to  be  in  the  position  which  normally  should  be 
occupied  by  Cowper's  glands. 

Treatment. — Complete  early  removal  would  give  the  only  hope  of 
success,  but  will  usually  be  impossible,  since  by  the  time  the  diagnosis 
is  made  and  the  patient  submits  to  operation  infiltration  will  have  pro- 
gressed too  far.  Death  is  likely  to  occur  within  the  year,  though  there 
is  one  recorded  case  of  survival  without  recurrence  for  nearly  two  years. 

URETHROSCOPY. 

Instruments  constructed  to  allow  of  visual  examination  of  the 
urethra  are  termed  endoscopes,  and  are  of  various  patterns.  Of 
these  the  best  are  the  ingenious  electrical  endoscopes  devised  by 
Valentine.  (Fig.  96.)  The  aero-urethroscope  is  so  planned  that 
after  introduction  of  the  tube  the  urethra  can  be  inflated  with 
air,  thus  exposing  a  long,  flat  wall,  in  place  of  the  small  circle  of 
lax  mucous  membrane  which  forms  the  field  of  vision  in  other  in- 
struments. 

The  light  required  in  these  examinations  may  be  reflected  from  a 

18 


274 


GEISriTO-URIIsrARY   DISEASES   AND   SYPHILIS. 


head-mirror,  or,  far  better,  may  be  furnished  by  a  small  electric  lamp, 
a  very  small,  cold  one,  passed  to  the  inner  end  of  the  tube.  The 
electricity  is  furnished  by  a  dry-cell  battery,  which  can  be  obtained  at 
moderate  cost. 

The  endoscopic  tubes  vary  in  calibre  and  length  according  to  the 
size  of  the  urethra  and  the  depth  to  which  an  examination  must  be 
carried.  It  is  evident  that  the  shorter  the  tube  and  the  wider  its 
calibre  the  more  distinct  will  be  the  image  presented.  The  tubes 
vary  in  size  from  No.   22  to  No,  32  French  calibre,  and  may  be 

Fig.  96. 


Valentine's  endoscope. 


longer  as  the  calibre  is  wider ;  thus,  No.  24  F.  should  be  about  three 
inches  in  length ;  No.  26,  four  inches ;  No.  28,  five  inches ;  No.  30, 
five  and  a  half  inches  ;  No.  32,  six  inches.  The  flattened  disk  at  the 
end  of  this  tube  enables  even  the  shorter  instrument  to  be  carried 
almost,  if  not  quite,  to  the  membranous  urethra,  since  after  the  tube 
is  introduced  to  its  full  length  the  head  of  the  penis  is  pushed  back 
by  the  disk  on  its  end. 

In  addition  to  the  endoscope,  applicators  are  required,  for  the 
purpose  of  removing  secretions  which  may  obscure  the  field  of  vision 
and  for  carrying  medication  to  diseased  mucous  surfaces.  These  may 
be  made  of  wire  Avith  cotton  wrapped  about  their  roughened  ends,  or 
long,  straight  splinters  of  wood,  or  split  straws  barbed  at  the  end,  may 
be  employed.  Before  beginning  an  examination  a  sufficient  number 
of  applicators  should  be  prepared.     Several  dozen  may  be  required. 

Examination. — This  may  be  conducted  with  the  patient  in  a  half- 
sitting  position  in  a  chair  or  in  a  recumbent  position  upon  a  lounge  or 
a  table.     For  a  thorough  examination  the  patient  should  be  drawn 


URETHKOSCOPY. 


275- 


down  to  the  foot  of  the  table  till  his  buttocks  rest  upon  its  lower  edge. 
The  thighs  are  separated  and  the  feet  are  supported  on  foot-holders 


Fig.  97. 


Chet wood's  urethroscope. 


properly  placed,  or  the  legs  and  thighs  may  be  allowed  to  hang.     The 
surgeon  then  selects  an  endoscopic  tube  as  large  as  the  urethra  will 


Fig.  98. 


Swinburne  urethroscope. 


take,  inserts  the  obturator,  lubricates  the  instrument,  and,  drawing 
the  penis  directly  upward  from  the  body,  separates  the  lips  of  the 


276  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

meatus  and  slowly  introduces  the  tube  by  pressure  upon  the  handle 
of  the  obturator  until  it  will  go  no  farther.  Unless  there  is  stricture 
or  some  abnormal  obstruction,  this  would  indicate  that  the  rounded 
end  of  the  obturator  has  encountered  the  resistance  due  to  the  ante- 
rior layer  of  the  triangular  ligament  and  to  the  tonic  spasm  of  the 
compressor  urethrse  muscle.  Usually  this  is  as  deep  as  it  is  necessary 
to  pass  the  instrument. 

When  inspection  of  the  posterior  urethra  is  indicated,  the  disk  end 
of  the  endoscopic  tube  is  depressed  between  the  thighs  until  the  tube 
lies  nearly  parallel  with  the  plane  of  the  body.  At  the  same  time 
gentle  inward  pressure  upon  the  handle  of  the  obturator  is  made. 
By  continued  pressure  the  compressor  urethrse  may  be  made  to  yield, 
and  the  instrument  then  passes  into  the  prostatic  urethra.  It  can  be 
passed  completely  into  the  bladder,  but  when  the  posterior  urethra 
must  be  inspected,  a  tube  with  a  curved  end,  the  convexity  of  which  is 
fenestrated,  causes  less  traumatism. 

The  tube  having  been  introduced  to  the  required  depth  is  held  in 
place  by  the  fingers  of  the  left  hand,  while  with  the  right  the  obtu- 
rator is  withdrawn  and  the  illuminating  apparatus  secured  in  place. 
The  field  of  vision  is  usually  obstructed  by  pus,  mucus,  or  blood. 
Such  fluids  must  be  removed  by  means  of  the  cotton  applicators 
before  a  clear  view  can  be  obtained. 

The  inspection  is  conducted  by  slowly  withdrawing  the  tube,  using 
the  cotton  applicators  to  cleanse  exposed  surfaces  from  discharge.  In 
case  the  instrument  has  been  carried  in  as  far  as  the  internal  vesical 
sphincter,  the  disk  is  elevated  as  it  is  withdrawn,  so  that  the  endo- 
scopic tube  shall  correspond  in  direction  to  that  of  the  urethra.  As 
the  penile  portion  of  the  urethra  is  inspected,  the  disk  is  withdrawn 
from  the  glans,  and  the  penis,  sagging  down,  may  prevent  the  tube 
of  the  endoscope  from  being  concentric  with  the  urethral  canal,  or 
the  weight  of  the  penis  may  cause  it  to  drop  entirely  away  from  the 
endoscope.  To  prevent  this,  as  the  instrument  is  drawn  out  the 
thumb  and  finger  of  the  left  hand  shift  their  grasp  from  the  disk  to 
the  tube,  while  the  penis  is  supported  between  the  ring  and  little 
fingers  of  the  same  hand. 

Urethral  stricture  or  a  small  meatus  may  temporarily  prevent  the 
introduction  of  an  endoscopic  tube.  Instrumentation  or  cutting  is 
then  indicated  to  bring  the  urethra  to  its  normal  calibre.  Bleeding  may 
seriously  interfere  with  a  satisfactory  urethroscopic  examination.  This 
if  slight  will  stop  spontaneously,  or  may  be  checked  by  cotton  appli- 
cators soaked  with  a  two  per  cent,  eucaine  in  a  1  to  1000  adrenalin 
solution  applied  on  a  swab.     Profuse  bleeding  generally  comes  from 


UKETHEOSCOPY.  277 

an  inflamed  posterior  urethra,  and  is  due  to  the  bruising  occasioned 
by  the  passage  of  the  instrument. 

The  urethroscopic  examination  should  be  preceded  and  followed 
by  an  antiseptic  flushing  of  the  anterior  urethra. 

Appearance  of  the  Urethra. — In  an  examination  of  the  urethra 
the  following  points  are  to  be  carefully  considered  (Griinfeld) : 

1.  The  cone-like  figure  which  the  urethral  walls  assume  beyond 
the  end  of  the  endoscope.  This  is  due  to  the  natural  elasticity  of  the 
urethra  and  the  contraction  of  its  muscular  fibres. 

2.  The  color,  the  thickness,  and  the  vascularity  of  the  walls  of  this 
cone. 

3.  The  central  point  or  figure,  that  is,  the  appearance  presented 
by  the  closed  lumen  of  the  urethra  which  forms  the  apex  of  the 
cone.  The  form,  the  size  or  length,  and  the  position  of  this  figure 
are  important. 

Every  portion  of  the  urethral  mucous  membrane  must  be  sub- 
jected to  careful  examination.  In  inspecting  the  cone  and  its  apex, 
the  central  point  or  figure,  the  endoscopic  tube  is  kept  parallel  with 
the  urethral  axis  at  the  point  of  examination.  For  more  direct  in- 
spection of  the  urethral  walls,  however,  it  becomes  necessary  to  give 
the  endoscope  a  different  relative  position.  When  the  endoscope  is 
turned  slightly  away  from  the  axis  of  the  urethra,  thus  exposing 
more  directly  the  parietes  and  carrying  the  central  figure  towards 
the  periphery  of  the  picture  presented,  the  position  is  said  to  be  ec- 
centric. When  the  endoscope  makes  such  a  distinct  angle  with  the 
urethral  axis  that  the  central  figure  disappears  entirely,  and  in  place 
there  is  seen  a  flat  surface  of  the  urethral  wall,  the  position  is  said 
to  be  parietal.  Thus  the  upper,  the  lower,  and  the  lateral  walls 
of  the  urethra  are  inspected  directly  each  time  a  new  urethral  sur- 
face is  exposed  by  drawing  out  the  endoscope  for  one-quarter  to 
one-half  inch.  In  making  a  complete  examination,  it  is  well  by  vary- 
ing the  pressure  to  alter  the  relations  of  the  cone  and  central  figure 
to  the  urethroscopic  tube,  now  slightly  withdrawing,  now  slightly 
pushing  it  in. 

Starting  from  the  prostatic  portion  of  the  normal  posterior  urethra 
and  using  a  full-sized  urethroscope  with  a  curved  end,  a  surface  of 
dark-red  mucous  membrane  is  observed.  As  the  instrument  is  with- 
drawn rather  suddenly  there  rises  from  directly  below,  if  the  endo- 
scope is  held  precisely  in  the  middle  line,  or  from  one  side  when  the 
instrument  is  lateralized,  a  smooth,  rounded,  polypoid  mass,  the  caput 
gallinaginis.  This  fills  the  greater  part  of  the  field  of  vision  and  is.  of 
a  brighter  red  than  the  surrounding  urethra.     If  the  distal  end  of  the 


278  GENITO-UEINARY   DISEASES   AXD    SYPHILIS. 

urethroscope  is  now  raised  somewhat  so  that  this  projection  occupies 
almost  the  entire  field  of  vision,  the  opening  of  the  sinus  pocularis, 
sometimes  sealed  by  a  drop  of  viscid  matter,  can  often  be  seen.  As 
the  endoscope  is  still  further  withdrawn,  the  ridge  projecting  in  advance 
of  the  sinus  pocularis  forms  a  distinct  fold  on  the  floor  of  the  urethra, 
over  which  is  stretched  the  mucous  membrane  of  the  roof  and  sides 
of  this  canal,  forming  a  crescentic  fold  less  distinctly  marked  from 
behind  forward.  The  mucoiis  membrane  becomes  finally  less  red  as 
the  membranous  part  of  the  urethra  is  reached. 

For  inspection  of  the  anterior  urethra  a  straight  endoscopic  tube  is 
used.  If  the  end  of  this  instrument  be  introduced  just  w^ithin  the  grasp 
of  the  compressor  urethrfe  muscle,  a  punctate  central  figure  is  formed 
with  radial  folds  of  mucous  membrane  extending  from  the  periphery 
towards  it.  The  endoscope  being  withdrawn,  its  end  escapes  from  the 
grasp  of  the  compressor  urethras  muscle,  and  unless  the  instrument  be 
held  firmly  may  be  thrust  strongly  forward  by  the  contraction  of  the 
ischio-cavernosus  and  bulbo-cavernosus  muscles.  If,  however,  the  ex- 
tremity of  the  endoscope  is  retained  in  the  region  of  the  bulb,  its  distal 
extremity  being  at  the  same  time  carried  upward  so  that  it  stands  at  right 
angles  to  the  plane  of  the  body,  the  action  of  these  muscles  can  be  dis- 
tinctly seen  in  the  alteration  which  takes  place  in  the  central  figure. 
This  in  place  of  appearing  as  a  cone  is  converted  into  a  vertical  slit, 
with  mucous  membrane  bulging  forward  on  either  side.  This  change  of 
form  is  due  to  the  lateral  pressure  produced  by  the  bulbo-cavernosus 
and  ischio-cavernosus  muscles.  The  mucous  membrane  is  here  pale 
red,  but  from  pressure  of  the  instrument  may  be  made  to  appear 
almost  white.  As  the  urethroscope  is  slowly  withdrawn,  and  as  its 
extremity  passes  into  the  pendulous  urethra,  the  figure  presented  is 
again  conical,  the  central  figure  appearing  as  a  transverse  slit,  with 
radial  folds  of  various  depths.  The  color  is  a  pale  red.  On  pressure 
of  the  instrument  the  openings  of  the  glands  and  follicles  can  readily 
be  seen  as  minute  pin-point  spots,  perhaps  a  little  deeper  in  color  than 
the  surrounding  mucous  membrane.  As  the  urethroscope  reaches 
the  navicular  fossa  the  central  figure  again  changes  in  shape,  appear- 
ing first  triangular,  then  at  the  meatus  as  a  vertical  slit ;  the  mucous 
membrane  becomes  purplish  in  color. 

The  Use  of  the  Endoscope. — During  the  acute  stage  of  urethritis  the 
use  of  the  endoscope  is  undesirable  ;  when,  however,  the  disease  has 
become  chronic  and  when,  in  spite  of  well-conducted  and  sufficiently 
prolonged  treatment,  discharge  or  other  symptoms  persist,  an  endo- 
scopic examination  is  often  useful. 

The  appearance  presented  by  the  pathological  urethra  is  simply 


THE    CARE    OF   UKETHRAL   INSTRUMENTS.  279 

more  or  less  a  modification  of  that  already  described  as  characteristic 
of  the  normal  canal.  The  conical  field,  the  color,  and  the  central 
figure  are  all  altered.  Thus,  when  the  inflammation  is  subacute  the 
mucous  membrane  is  greatly  swollen,  soft,  and  succulent,  and  the  nor- 
mal cone  is  practically  obliterated,  the  walls  of  the  urethra  coming 
directly  together,  sometimes  even  projecting  into  the  lumen  of  the 
endoscopic  tube.  When  the  subepithelial  infiltration  has  undergone 
organization  the  cone-like  figure  becomes  greatly  elongated,  and  the 
central  figure  may  be  triangular,  quadrilateral,  or  in  other  ways  irreg- 
ular in  shape. 

Color  alterations  are  usually  marked.  The  tint  becomes  dark  red  or 
even  purplish,  and  may  appear  in  patches  or  may  invade  the  greater 
part  of  the  urethra.  In  place  of  the  normal  lustrous  urethral  surface 
the  mucous  membrane  may  appear  either  shining  and  oedematous  or 
dull.  Exceptionally  the  surface  is  granular,  either  over  a  considerable 
area  or  in  localized  patches. 

The  openings  of  Morgagni's  follicles  are  often  large,  patulous,  and 
purplish.  Sometimes  there  are  distinct  epithelial  outgrowths.  Areas 
of  corneous  epithelium  indicative  of  subepithelial  cicatrization  appear 
as  white  patches.  In  chronic  inflammation  of  the  posterior  urethra 
the  mucous  membrane  is  purplish,  swollen,  oedematous,  hypersensitive, 
and  bleeds  readily. 

The  endoscope  will  thus  enable  the  surgeon  to  discover  and  locate 
circumscribed  areas  of  inflammation,  chronically  inflamed  lacunae 
and  follicles,  subepithelial  infiltration,  vegetations  or  polypi,  stric- 
tures, and  urethral  calculi.  Through  it  strong  applications  may  be 
made  to  diseased  areas.  Suppurating  follicles  may  be  readily  split 
up  and  cauterized.  The  nature  and  position  of  foreign  bodies  may 
be  determined.  Polypi  may  be  removed.  The  anterior  opening  of 
eccentric  strictures  may  be  discovered. 


THE   CARE   OF   URETHRAL   INSTRUMENTS. 

The  instruments  used  in  urethral  surgery  are  of  metal,  woven 
thread  coated  with  gum,  india-rubber,  or  whalebone.  The  metal 
instruments  include  the  knives,  urethrotomes,  urethroscopic  tubes, 
sounds,  and  catheters. 

The  knives,  and  especially  the  smafl  blades  used  in  the  urethro- 
tomes, should  have  a  smooth  razor  edge,  and  should  be  freshly  pre- 
pared for  each  operation.  They  are  sterilized  by  boiling  in  soda 
solution  (one  to  three   per   cent.)  not   longer  than  one  minute,  as 


280  GENITO-UEINARY  DISEASES   AND   SYPHILIS. 

prolonged  boiling  invariably  blunts  a  keen  edge.  If  they  have  been 
carefully  cleansed  by  soap  and  hot  water  and  are  free  from  rust,  one 
minute's  boiling  is  sufficient  to  render  them  sterile. 

The  urethrotomes  are  boiled  for  ten  minutes  in  soda  solution, 
but  before  being  immersed  are  carefully  tried  to  see  that  they  work 
smoothly  and  easily.  Immediately  after  being  used  they  should  be 
taken  apart  completely,  scrubbed  in  hot  water  and  green  soap,  dried 
out  of  boiling  soda  solution,  and  put  together.  It  is  well  to  place  them 
in  an  oven  at  about  boiling  temperature  for  five  minutes  to  insure 
thorough  drying.  They  should  then  be  wrapped  in  dry  sterile  gauze 
and  stored  in  drawers,  or,  better  still,  in  a  dry  closed  box. 

The  urethroscopic  tubes  are  either  silver-  or  nickel-plated ;  they 
are  sterilized  by  boiling  in  soda  solution  or  by  flaming  with  alcohol. 
After  use  they  are  washed  and  swabbed  out  with  hot  soap  and  water, 
washed  in  soda  solution,  and  thoroughly  dried.  Their  outer  surface 
must  be  perfectly  smooth,  and  the  obturator  must  fit  the  urethral 
opening  accurately.  The  edges  of  the  latter  should  be  bevelled  in 
slightly.  It  is  well  to  keep  each  separate  tube  wrapped  in  sterile 
gauze,  thus  preventing  denting  or  bruising  of  the  plating. 

The  sounds  and  metal  catheters  must  present  a  perfectly  smooth 
polished  surface.  The  slightest  irregularity  which  can  be  detected  by 
the  sense  either  of  sight  or  of  feeling  is  sufficient  ground  for  having 
the  instrument  reburnished  or  replated.  These  instruments  should 
be  kept  in  boxes  or  racks  so  arranged  that  each  instrument  is  held 
firmly  in  its  place  and  is  not  liable  to  bruise  or  dent  its  fellows.  The 
sounds  may  be  sterilized  either  by  boiling  in  soda  solution  or  by  being 
dipped  in  alcohol  to  a  depth  sufficient  to  wet  all  the  instrument  ex- 
cept the  handle.  The  alcohol  is  then  ignited,  and  in  burning  causes 
enough  surface  heat  to  render  the  sound  sterile.  Before  this  flaming, 
instruments  should  be  polished  for  a  moment  by  brisk  friction  with  a 
clean  towel.  Metal  catheters  should  be  sterilized  by  boiling  in  soda 
solution.  Before  subjecting  them  to  this  process  it  is  well  to  be 
assured  that  their  canals  are  not  blocked,  and  in  the  case  of  the 
Gouley  catheter  that  the  obturator  is  movable,  and  that  the  "  tunnel" 
is  sufficiently  large  to  accommodate  the  filiform  bougie  over  which  it 
is  to  be  passed.  After  having  been  used  the  catheters  should  be 
cleansed  immediately. 

None  of  the  lubricants  commonly  employed  injure  metal  instru- 
ments. The  lubricant  chosen  should  be  placed  in  a  narrow  speci- 
men jar  so  deep  that  the  entire  shaft  of  the  instrument  can  be  dipped. 
By  placing  this  jar  in  the  steam  sterilizer  for  ten  minutes  every  day 
its  contents  can  be  kept  absolutely  sterile.     Of  the  oily  substances, 


THE   CAEE    OF    URETHRAL    INSTRUMENTS.  281 

fluid  albolene  and  castor  oil  are  the  best.  The  objection  to  these  and 
similar  lubricants  is  based  upon  the  fact  that  they  make  the  subse- 
quent cleaning  of  the  instruments  difficult,  and  in  the  case  of  soft  gum 
and  rubber  instruments  produce  a  rapid  deterioration  in  their  strength 
and  surface  polish. 

We  have  been  well  satisfied  with  the  following  preparation,  which 
is  not  irritating,  and  is  easily  removed  by  water : 

B  Boroglyceride,    ,^iii  ; 
Aquae  destil.,  f§ix. 
M.      S. — Use  as  a  lubricant  for  sounds. 

The  soft  urethral  instruments,  india-rubber  and  woven  gum- 
coated  bougies,  catheters,  and  whalebone  filiforms,  are  much  more 
difficult  to  sterilize  and  to  keep  serviceable  than  are  the  metal  instru- 
ments. The  flexible  india-rubber  catheters  are,  fortunately,  rather 
benefited  than  otherwise  by  boiling  in  water :  hence  their  thorough 
sterilization  is  readily  accomplished.  All  fats  act  injuriously  upon  the 
rubber,  causing  it  to  swell  and  soften  and  to  become  so  weak  that  it 
is  unsafe  for  use.  This  action  is  not  noticeable  for  several  weeks. 
Ultimately  these  india-rubber  instruments  if  unused  become  brjittle. 
They  are  so  cheap  that  they  can  be  replaced  readily  when  they  show 
signs  of  deterioration.  The  woven  bougies  and  catheters  are  coated 
with  a  varnish  which  should  exhibit  an  absolutely  smooth  finish. 
The  best  are  those  made  so  that  they  can  withstand  the  temperature 
of  boiling  water,  though  if  frequently  sulDJected  to  this  process,  or  if  the 
boiling  is  long  continued,  the  varnish  becomes  irregular  and  blistered. 
If  the  mechanical  cleansing  of  these  instruments  is  efficiently  carried 
out,  boiling  in  water  for  five  minutes  is  sufficient  to  sterilize  them. 
Each  should  be  separately  wrapped  in  sterile  gauze  before  being  boiled. 

Janet  and  Guyon  found  formaldehyde  to  be  an  efficient  antiseptic 
for  the  sterilization  of  urethral  instruments.  The  method  of  applying 
the  disinfectant  is  as  follows. 

A  metal  box  is  made  varying  in  size  in  accordance  with  the  re- 
quirements. (Fig.  99.)  That  designed  for  genito-urinary  cHnics  or 
for  the  specialist  is  eighteen  inches  long,  seven  inches  wide,  and  four 
inches  high,  hermetically  closed  by  a  metallic  cap  with  a  rubber 
washer,  and  provided  with  eight  shelves  made  of  perforated  metal. 
These  shelves  can  be  stored  in  the  upper  part  of  the  box  when  they 
are  not  required.  In  the  bottom  of  the  box  there  is  a  frame  upon 
which  can  be  stretched  a  piece  of  cloth  twelve  inches  long  and  four 
inches  wide.  This  cloth  is  placed  above  the  floor  of  the  box,  and 
thus  allows  of  rapid  evaporation  of  the  formaldehyde  which  is  poured 


282 


GENITO-UKII^ARY   DISEASES    AND   SYPHILIS. 


upon  it.  Upon  this  cloth  can  also  be  spread  finely  powdered  para- 
form  ;  it  should  be  sprinkled  in  a  shallow  layer  over  the  entire  surface. 
This  apparatus  readily  holds  two  hundred  instruments,  each  of  which 
can  be  kept  entirely  separate  from  the  others. 

A  similar  box  is  designed  for  patients  who  are  required  to  sterilize 
their  own  sounds  and  for  doctors  who  only  occasionally  use  instru- 
ments. This  is  seventeen  inches  long,  three  inches  high,  and  three 
inches  wide.  One  end  is  closed  by  a  soft  rubber  cap.  It  contains  two 
shelves, — the  upper  movable,  the  lower  fixed, — and,  below,  a  movable 
frame  over  which  a  cloth  can  be  stretched  or  a  layer  of  absorbent 
cotton  spread.  This  allows  of  the  sterilization  of  from  sixteen  to 
twenty  instruments.     It  is  also  large  enough  to  contain  a  cystoscope. 

The  box  designed  for  patients  who  are  recjuired  to  sterilize  their 
own  catheters  should  be  of  such  size  that  a  sufficient  number  can  be 
stored  to  last  two  days,  a  fresh  instrument  being  used  each  time. 

Fig.  99. 


Sterilizing-box  for  soft  urethral  instruments. 


A  diploma  case,  provided  with  a  central  removable  core  of  wire  or 
perforated  metal,  divided  into  the  required  number  of  compartments, 
answers  well.  In  one  cap  of  the  case  is  placed  a  pledget  of  absorbent 
cotton,  and  on  this  is  poured  one  drachm  of  formaldehyde  (forty  per 
cent.).  The  cap  is  then  placed  on  and  fastened  with  adhesive  plaster. 
The  catheters  are  boiled,  dried,  placed  in  the  compartment,  and  the 
box  closed. 

Formaldehyde  is  particularly  adapted  to  the  sterilization  of  bougies 
and  catheters  of  large  calibre,  an  exposure  of  twenty-four  hours  being 
sufficient.  There  may,  however,  be  failure  when  small  quantities  of 
formaldehyde  are  employed,  when  the  temperature  of  the  surrounding 
atmosphere  is  low,  or  when  an  attempt  is  made  to  sterilize  small 
catheters  with  very  fine  canals,  or  irrigating  cystoscopes.  It  is  probable 
that  all  these  instruments  could  be  thoroughly  sterilized  by  a  more 
prolonged  exposure, — forty-eight  to  seventy-two  hours.  It  is  essential 
to  employ  formaldehyde  of  full  strength  (forty  per  cent,  volume  in  solu- 
tion), spread  over  a  considerable  surface,  to  keep  the  temperature  of 


THE    CARS    OF    URETHRAL   INSTRUMENTS.  283 

the  surrounding  atmosphere  above  56°  F.,  and  not  to  attempt  to  secure 
sterilization  in  a  shorter  period  than  twenty-four  hours  for  large- 
calibred  catheters,  or  forty-eight  hours  for  catheters  of  fine  calibre  and 
for  simple  cystoscopes,  which  must  have  been  washed  previously. 
Irrigating  cystoscopes  and  ureteral  catheters  cannot  be  sterilized  cer- 
tainly except  after  much  longer  exposure. 

After  prolonged  exposure  to  formaldehyde  instruments  remain  as 
smooth,  supple,  and  shining  as  when  they  were  first  subjected  to  the 
influence  of  the  antiseptic.  No  action  is  perceptible  upon  the  metallic 
portions.  Ultimately  flexible  bougies  become  somewhat  softer  than 
at  first,  probably  because  they  are  kept  in  a  moist  atmosphere.  The 
softening  is  so  slight  that  it  is  of  no  serious  consequence. 

Instruments  taken  directly  from  a  strong  formaldehyde  vapor  and 
introduced  into  the  urethra  occasion  a  slight  stinging  sensation.  This 
is  avoided  by  a  preliminary  washing  in  boric  acid  solution. 

Ingiani  has  thus  sterilized  ureteral  catheters.  To  the  mouth  qf 
the  ordinary  test-tube  he  attaches  a  rubber  tube  of  appropriate  size 
and  about  1|  feet  long.  In  the  free  end  of  this  rubber  tube  is  placed 
a  perforated  cork,  in  the  test-tube  is  placed  a  saturated  solution  of  sul- 
phate of  soda.  The  ureteral  catheter  is  then  passed  through  the  rubber 
tube  until  its  end  lies  in  the  bottom  of  the  test-tube.  The  perforated 
cork  closes  the  opening  of  the  rubber  and  in  the  ordinary  flame  the 
test-tube  is  boiled  for  one  minute,  the  steam  escaping  through  the 
perforation  of  the  cork  and  the  rubber  tube. 

If  the  patient  is  required  to  pass  an  instrument  on  himself,  say 
four  times  daily,  he  should  have  eight  catheters  in  the  small  box 
already  described.  Four  of  these  catheters  are  placed  upon  the  upper 
shelf  and  four  upon  the  lower,  and  trioxymethylene  is  put  in  place. 
Each  time  an  instrument  is  used  the  patient  takes  one  catheter  from 
the  upper  shelf.  After  having  drawn  his  water,  he  washes  the  cath- 
eter and  puts  it  aside.  The  next  day  the  four  catheters  that  have 
been  used  are  soaped  and  washed,  dried  as  thoroughly  as  possible, 
and  put  back  upon  the  upper  shelf,  the  patient  then  proceeding  to 
utilize  those  upon  the  lower  shelf.  The  cap  should  be  removed  and 
replaced  as  rapidly  as  possible  each  time,  and  a  drachm  of  formal- 
dehyde solution  should  be  spread  over  the  cotton  once  daily. 

For  the  general  practitioner  who  rarely  employs  catheters,  it  is 
best  to  place  the  instruments  that  he  is  most  likely  to  use  in  the  ster- 
ilizing box  and  leave  them  there  indefinitely  until  they  are  required. 
The  formaldehyde  difl'uses  in  two  or  three  days,  and  there  is  then  no 
need  to  dip  the  instruments  into  a  mild  antiseptic  solution  before  they 
are  used. 


284  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

Whalebone  filiform  bougies  may  be  conveniently  sterilized  by  the 
formalin  process.  In  storing  these  instruments,  it  is  well  to  remem- 
ber that  they  are  attacked  by  a  parasite,  which  so  roughens  and 
weakens  them  that  they  become  unfit  for  use :  hence  they  should  be 
slightly  lubricated  with  albolene  or  cosmoline  and  kept  in  a  tight  box. 

The  rules  applicable  to  the  care  of  soft  instruments  are  that  they 
should  be  kept  straight  and  not  coiled ;  that  they  should  not  be 
allowed  to  lie  in  contact  with  one  another,  this  being  prevented  by 
wrapping  each  in  sterile  gauze ;  that  they  should  be  thoroughly 
washed,  and,  in  the  case  of  catheters,  flushed  out,  immediately  after 
being  used,  and  be  dried  by  wiping,  shaking,  and  finally  by  exposure 
to  dry  heat  at  about  150°  F.  They  should  be  thrown  aside  as  sooa 
as  the  surface  becomes  rough,  irregular,  or  blistered. 


CHAPTER  VIII. 

THE     GENERAL     SYMPTOMATOLOGY     OF     DISEASES     OF    THE     URINARY     TRACT. 

EXAMINATION    OF    THE    URINE. 

Pain. — Pain  symptomatic  of  pathological  conditions  of  the  urinary 
tract  is  subject  to  so  many  variations  in  degree,  is  so  often  referred 
to  regions  other  than  the  seat  of  disease,  and  is  so  affected  by  vesical 
tension  and  by  micturition,  that  a  serviceable  classification  of  the 
manifestations  of  this  symptom  is  difficult.  Perhaps  the  subject  may 
he  best  considered  under  the  following  heads : 

1.  The  character  and  intensity  of  pain. 

2.  The  region  of  pain. 

3.  The  relation  of  pain  to  the  act  of  micturition. 

The  Character  and  Intensity  of  Pain. — Pain  symptomatic  of 
urinary  affections  may  vary  from  an  apparent  muscular  stiffness 
comparable  to  that  following  active  exertion,  and  noticed  only  on 
movement,  or  from  a  dull  ache  readily  forgotten  when  the  mind  is 
employed,  to  a  severe  pain  distracting  the  attention  and  seriously 
interfering  with  the  business  of  life,  or  to  an  unbearable  anguish  pro- 
ducing vomiting,  syncope,  and  sometimes  death. 

The  pain  may  be  aching  and  rheumatoid,  as  in  renal  congestion, 
may  be  burning,  as  in  cases  of  prostato-cystitis,  may  be  shooting  and 
lancinating,  as  in  vesical  neuralgia,  or  may  be  tearing  and  griping,  as 
in  renal  cohc. 

It  may  be  steady,  as  in  vesical  carcinoma,  it  may  be  intermittent, 
as  in  bladder  stone,  or  it  may  be  continuous  with  violent  exacer- 
bations, as  in  calculous  pyelitis  or  acute  hydronephrosis.  If  the  suffer- 
ing incident  to  acute  blocking  of  the  ureter  be  excepted,  most  of  the 
pain  of  urinary  disease  comes  from  the  bladder  and  prostatic  urethra. 

Diseases  of  the  kidney  and  its  pelvis  are  comparatively  painless, 
provided  there  is  free  drainage  through  the  ureter.  A  calculous  pye- 
litis may  last  for  years  with  no  symptoms  other  than  backache,  aggra- 
vated on  motion,  or  there  may  be  frequent  paroxysms  of  agonizing 
pain,  and  indeed  this  may  occur  in  pyelitis  without  calculi.  These 
paroxysms  are  due  to  acute  retention,  caused  by  valvular  formation, 
plugging  of  the  ureter  by  pus  or  blood,  or  blocking  of  it  by  calculus. 

Inflammation  of  the  ureters  in  itself  occasions  no  pain  which  can 
be  recognized  as  characteristic.     It  is,  however,  so  frequently  compli- 

285 


286  GENITO-URINAEY    DISEASES    AND   SYPHILIS. 

cated  by  partial  or  complete  stoppage,  with  consequent  tension  of 
the  kidney  capsule,  that  patients  suffering  from  this  form  of  inflam- 
mation are  subject  to  violent  attacks  of  colic.  The  absolutely  unbear- 
able pain  of  a  kidney  stone  passing  along  the  ureter  is  probably  due 
more  to  spasmodic  mechanical  blockage  of  this  canal  and  consequent 
retention  of  urine  in  the  kidney  pelvis  than  to  mechanical  erosions 
caused  by  the  passage  of  an  irregular  foreign  body.  This  hypothesis 
would  seem  to  be  confirmed  by  the  comparative  painlessness  of 
ureteral  catheterizations. 

The  pain  of  bladder-disease,  aside  from  that  caused  by  muscular 
contraction  incident  to  micturition,  is  proportionate  to  the  intensity 
of  the  pathological  process.  Chronic  cystitis  causes  very  little  pain. 
Acute  cystitis  and  acute  retention  are  extremely  painful. 

The  suffering  incident  to  inflammation  or  erosion  due  to  a  calcu- 
lus or  a  foreign  body  varies  greatly.  In  general,  large  smooth  calculi 
are  less  painful  than  those  which  are  small  and  irregular.  Malignant 
growth  of  the  bladder  may  be  absolutely  painless  until  it  becomes 
compUcated  by  cystitis  or  infiltrates  the  muscular  walls.  Even  under 
these  circumstances  pain  may  be  slight  or  bearable.  It  is  often,  how- 
ever, constant,  subject  to  spasmodic  exacerbations,  and  more  intense 
and  wearing  than  any  other  form  of  vesical  pain  except  that  due  to 
retention. 

Tubercular  ulceration  may  be  painless,  except  during  and  after 
micturition.  When  the  lesions  are  situated  in  the  trigonum  they  may 
cause  constant  burning  wearing  pain,  with  reflexes  to  the  rectum, 
anus,  perineum,  and  inner  surfaces  of  the  thighs. 

The  Region  of  Pain.— Pain  may  be  felt  in  the  region  involved. 
Thus,  in  acute  hydronephrosis  or  chronic  pyelitis  the  pain  is  con- 
stantly referred  to  the  region  of  the  kidney,  though  reflexes  may  be 
so  pronounced  as  to  make  this  fact  apparent  only  after  careful  ques- 
tioning of  the  patient.  Inflammation  of  the  bladder  usually  causes 
pain  directly  in  the  vesical  region. 

Sometimes  no  pain  is  experienced  at  the  seat  of  lesion,  the  abnor- 
mal sensation  being  referred  to  anastomosing  nerve-trunks  or  to  the 
terminal  extremities  of  the  nerve  irritated.  Thus,  disease  of  the  kid- 
neys constantly  gives  rise  to  pain  which  is  felt  chiefly  in  the  groin, 
down  the  thighs,  or  in  the  testicle.  The  irritation  caused  by  stone  in 
the  bladder  produces  urethral  pain,  felt  a  short  distance  back  from 
the  meatus.  Inflammation  of  the  trigonum  frequently  causes  itching, 
tickling,  and  painful  spasm  of  the  anal  sphincter. 

Occasionally  the  healthy  bladder  may  be  the  seat  of  almost  un- 
bearable pain,  due  entirely  to  inflammation  of  the  kidney  pelvis. 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINAEY  TKACT.        287 

The  pain  of  kidney-disease  of  one  side  may  be  referred  to  the 
opposite  healthy  side,  or  to  the  shoulder,  the  groin,  the  urethra,  the 
testicle,  the  inner  surface  of  the  thigh,  the  calf,  or  the  heel.  This 
pain  in  the  heel  is  particularly  a  reflex  from  the  prostatic  urethra. 

Pain  of  bladder-trouble  may  be  referred  to  the  suprapubic  region, 
the  sacral  or  lower  lumbar  vertebrae,  the  glandular  urethra,  the  kid- 
neys, the  perineum  and  anus,  the  inner  surface  of  the  thighs,  and 
the  sole  of  the  foot.  All  these  transferred  pains  may  be  symptoms  of 
inflammation  of  the  prostatic  urethra. 

Diffum  suprapubic  pain  generally  indicates  disease  posterior  to  the 
vesical  sphincter. 

If  constant,  it  will  suggest  advanced  vesical  atony,  vesical  carci- 
noma, severe  chronic  cystitis,  perivesical  abscess  or  inflammation,  and 
rarely  ureteral  disease. 

If  transient  in  duration  and  provoked  by  micturition,  it  suggests 
prostatic  enlargement  with  residual  urine.  When  increased  by  mic- 
turition, it  generally  means  vesical  tenesmus  in  a  partially  atonic 
bladder.  The  transient  suprapubic  pains  of  all  grades  of  cystitis,  tuber- 
culosis, and  ulceration  of  the  bladder  and  of  chronic  prostatic  inflam- 
mation are  all  relieved  by  micturition. 

Perineal  pain  always  signifies  disease  of  some  structure  in  inti- 
mate relation  with  the  bladder-neck,  or  base,  or  of  the  prostatic  or 
membranous  urethra. 
-  If  constant,  chronic  prostatitis,  beginning  prostatic  hypertrophy, 
carcinoma,  and  encysted  calculi  are  suggested.  If  transient  and 
relieved  by  micturition,  acute  inflammation  and  tubercular  disease  of 
the  prostate  or  vesical  trigone  must  be  considered.  When  increased 
by  micturition,  it  suggests  either  inflammation  posterior  to  the  vesi- 
cal trigone,  such  as  might  be  caused  by  calculi  pouched  behind  an 
enlarged  prostate,  or  tubercular  infiltration,  or  involvement  of  the 
bulbous  or  membranous  urethra,  such  as  would  result  from  sub- 
urethral abscess,  or  inflamed  stricture,  carcinoma,  or — rarely — tuber- 
culosis. 

Pain  referred  to  the  glans  penis,  whether  constant  or  occurring 
only  at  the  beginning  or  during  the  act  of  micturition,  always  implies 
disease  of  some  part  of  the  urethra  or  the  prostate. 

If  constant,  prostatorrhoea,  chronic  inflammation  of  the  prostatic 
urethra,  or  beginning  enlargement  of  the  prostate  gland  is  indicated. 

If  occurring  just  before  micturition,  urethral  obstruction  either 
from  clot  retention,  calculous  impaction,  or  senile  prostatic  enlarge- 
ment is  present. 

If  present  throughout  micturition,  it  may  be  due  to  some  local 


288  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

lesion  in  the  urethra ;  either  inflammation,  a  granular  patch,  ulcera- 
tion, neoplasm,  or  a  narrow  meatus. 

If  present  only  at  the  end  of  micturition,  it  may  be  due  to  a  patho- 
logical condition  at  or  near  the  internal  (vesical)  orifice  of  the  urethra, 
such  as  severe  prostatic  inflammation  or  congestion,  vesical  tumors 
impinging  on  the  internal  urethral  orifice,  inflammation  of  the  trigone, 
ulceration  of  the  posterior  or  lateral  walls  of  the  bladder,  any  form  of 
acute  localized  inflammation  in  any  part  of  the  bladder  causing  spasm 
involving  the  neck,  vesical  calculus,  or  the  vesical  spasm  of  renal  colic. 

The  Relation  of  Pain  to  the  Act  of  Micturition. — Pain  may  be 
experienced  before,  during,  or  at  the  completion  of  the  act  of  mictu- 
rition. The  pain  may  be  felt  in  the  bladder,  urethra,  deep  perineum, 
and  rectum,  or  in  the  regions  already  described  as  the  seats  of  prefer- 
ence for  reflexes.  It  is  subject  to  variations.  It  may  be  simply  a 
slight  ache,  or  may  be  burning,  shooting,  darting,  neuralgic,  and 
almost  unbearable. 

EVen  though  reflexes  are  present,  the  pain  is  usually  located  at 
the  seat  of  disease,  and  is  generally  more  or  less  persistent,  the  act 
of  urination  exaggerating  it. 

Pain  preceding  micturition  is  due  to  a  hyperaesthetic  condition 
of  the  vesical  mucosa  or  the  prostatic  urethra.  This  hyperaesthesia 
may  be  caused  by  various  neuroses,  by  congestion,  or  by  inflamma- 
tion,— the  tension  of  the  full  bladder  causing  distress.  If  the  urine  is 
strongly  acid  or  concentrated,  as  in  cases  of  rheumatism,  gout,  or 
acute  fevers,  even  the  healthy  mucosa  may  be  irritated,  and  may 
be  the  seat  of  burning  or  discomfort,  relieved  by  emptying  the  bladder. 
Exceptionally  pain  before  urinating  is  a  symptom  of  disease  of  the 
kidney  pelvis. 

Micturition  pain  is  also  occasioned  by  irritable  or  inflammatory 
conditions  of  the  bladder  or  prostate,  since  the  muscular  contraction 
required  to  expel  urine  necessarily  disturbs  the  hypersensitive  tissues. 
Ulceration  or  inflammation  of  the  vesical  neck  is  particularly  liable  to 
cause  urination  pain.  The  sensation  may  be  aching,  burning,  or 
shooting  and  darting,  distinctly  neuralgic  in  type. 

Pain  after  urination,  generally  considered  characteristic  of  stone, 
may  be  caused  by  any  inflammatory  or  ulcerative  condition  of  the 
bladder-neck.  In  many  cases  it  is  probably  due  to  fissure  or  erosion, 
and  is  comparable  to  the  pain  felt  after  defecation  in  cases  of  anal 
fissure.  The  probability  that  this  is  the  cause  of  the  severe  forms 
of  suffering  is  still  further  increased  by  the  fact  that  it  is  commonly 
associated  with  tenesmus  and  involuntary  contraction  of  all  the 
perineal  muscles,  and  that  it  is  relieved  by  local  applications. 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINARY  TRACT.        289 

Aside  from  pain  due  to  distinct  lesions  of  the  urinary  tract,  there 
is  apparently  a  pure  neurosis  characterized  by  continuous  or  inter- 
mittent pain  amounting  sometimes  to  veritable  anguish  felt  in  the 
bladder,  suprapubic  region,  or  perineum,  by  frequent  urination,  and, 
unless  the  desire  to  empty  the  bladder  is  at  once  gratified,  by  in- 
continence. There  is  usually  nocturnal  remission,  the  patient  sleep- 
ing soundly  for  several  hours.  The  symptoms  vary  in  intensity; 
active  pursuits,  either  of  mind  or  of  body,  caused  marked  temporary 
amelioration. 

Exploration  proves  the  urethra  and  bladder  to  be  exquisitely  sen- 
sitive. This  condition  is  termed  irritable  or  neuralgic  bladder,  and  is 
sometimes  a  symptom  or  prodrome  of  tabes,  though  it  is  more  com- 
monly a  reflex  from  the  rectum,  anus,  or  generative  organs.  It  has 
been  observed  in  association  with  influenza,  rheumatism,  gout,  and 
malaria. 

When  pain  at  the  end  of  urination  is  greatly  increased  by  exercise 
or  jolting,  and  is  relieved  by  rest  in  bed  and  by  urination  in  the  dorsal 
decubitus,  it  is  probably  due  to  calculus  or  to  foreign  body. 

The  pain  at  the  end  of  micturition  caused  by  tubercular  ulceration 
at  the  neck  of  the  bladder,  or  exceptionally  by  cystitis,  may  also  be 
relieved  by  rest  and  be  aggravated  by  motion,  but  not  to  the  same 
extent  as  is  observed  in  calculus. 

Chronic  inflammation  of  the  prostate  is  usually  characterized  by 
a  more  or  less  constant  pain  referred  to  the  sacrum.  In  seminal 
vesiculitis  this  pain  is  referred  to  the  hip-joint.  In  nephritis  or  pye- 
Htis  it  is  referred  to  a  point  just  below  the  last  rib  to  the  outer 
side  of  the  erecta  spinas  muscle  and  is  not  affected  by  the  act  of 
micturition. 

Frequency  of  Urination. — Most  men  empty  the  bladder  upon 
rising  in  the  morning,  during  the  after-breakfast  defecation,  at  noon, 
in  the  late  afternoon,  and  before  going  to  bed,  passing  from  six  to 
twelve  ounces  of  urine  at  each  act  of  micturition.  In  warm  weather 
urination  is  less  frequent,  the  skin  relieving  the  kidneys. 

The  bladder  is  said  to  be  irritable  when  the  desire  to  urinate 
comes  too  frequently.  This  irritability  may  be  entirely  of  psychic 
origin, — as,  for  instance,  the  frequent  micturition  of  the  student  sub- 
ject to  examination, — or  it  may  be  due  to  habit,  though,  unless  the 
frequency  be  continued  through  the  night,  this  does  not  lessen  the 
absolute  capacity  of  the  bladder. 

The  irritability  may  also  be  caused  by  reflexes  from  the  rectum, 
the  urethra,  the  prostate,  the  testicles,  or  the  kidneys. 

It  may  be  due  to  increased  secretion  on  the  part  of  the  kidneys, 

19 


290 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


as  in  diabetes.  In  this  case  the  bladder  is  not,  properly  speaking, 
irritable,  since  it  contains  urine  comfortably  up  to  its  full  normal 
capacity,  but  has  to  be  frequently  emptied  because  it  is  so  rapidly 
filled. 

The  frequency  of  quantity  and  of  irritability  are  thus  tabulated 
by  Fenwick : 

A. — The  Frequency  of  Quantity. 
(Much  urine,  which  is  passed  often.) 
High  r 

specific     \  Sugar.  Diabetes  mellitus. 

gravity.      ( 

No   sugar,  but   extreme 
thirst. 


Persistent 
excess. 


Transient 

excess 

(usually 

diurnal). 


Low 
specific 
gravity. 


Albumen  with  casts,  but 
without  pus  or  resid- 
ual urine. 


No    albumen,   but   with 
residual  urine. 


Diabetes  insipidus. 

Chronic  Bright's  disease, 
such  as  granular  kid- 
ney, amyloid  kidney  of 
advanced  scrofulous  or 
syphilitic  affections. 

Back  renal  pressure  from 
atony  or  direct  renal 
irritation  of  prostatic 
oris'in. 


Low 

specific 
gravity, 
clear. 


(a)  Sexual  excess  or  debility  (without  inflammation). 

Dietetic  idiosyncrasy, — tea,  beer,  etc. 
{b)  Hypochondriasis,  hysteria,  nervousness. 


L  Without 
obstruc- 
tion to 
the 
stream. 


2.  With  ob- 
struction 
to  the 
stream. 


B. —  The  Frequency  oj  Irritability. 
(Little  water,  which  is  passed  often.) 


(a)  With- 
out pus. 

{b)  With 
pus. 

(c)  W^ith 
prostatic 
"threads" 
of  pus. 

Diurnal. 

Nocturnal. 

Diurnal 
and    noc- 
turnal. 


Blood,  lithiasis,  phosphaturia,  oxaluria,  dyspepsia. 

Various  irritants  in  renal  pelvis  and  ureter, — e.g., 
stone,  tubercle.  Movable  kidney.  Cystitis  of  all 
grades.  Catarrhal  or  tubercular  ulceration  of  the 
bladder.     Hard  cancer. 

Micturition  reflex,  excited  by  transient  inflammation 
or  congestion  of  the  prostatic  mucous  membrane, — 
e.g.,  gout,  catarrhal  prostatitis,  masturbation,  pros- 
tatic tubercle,  and  stone. 

Stone,  stricture,  prostatitis,  muscular  atony  of  low- 
degree,  vascular  growths  of  female  urethra. 

Enlarged  and  congested  prostate  without  much  resid- 
ual urine. 


Enlarged  prostate   with   residual   urine, 
prostate. 


Cancer  of 


SYMPTOMATOLOGY  OF  DISEASES  OF  UEINAEY  TEACT.        291 


The  fre- 
quency 
of    inca- 
pacity. 


The  fre- 
quency 
of    over- 
flow. 


Frequency 
at  night 
nearly 
as  pro- 
nounced 
as  in  day. 


Age,  30-45. 
Age,  45-70. 


C. — Physical  Irritability. 

Non-inflammatory     con- 
ditions. 


Inflammatory  conditions. 


Contraction  due  to  habit. 

Contraction  due  to  obso- 
lete or  advanced  tuber- 
cle of  the  bladder ;  to 
advanced  interstitial 
cystitis  following  gonor- 
rhoea, stone,  enlarged 
prostate,  perimetritis. 


Spinal  atony  (tabes),  advanced  stricture. 
Advanced  atony  of  prostatic  enlargement. 


The  treatment  of  frequent  urination  is  founded  on  the  detection 
and  removal  of  the  cause,  and  is  given  in  the  sections  devoted  to  the 
consideration  of  cystitis,  stone,  stricture,  cancer,  etc. 

There  is,  however,  one  form  of  frequent  urination  vi^hich  appar- 
ently is  purely  functional.  In  the  absence  of  urethral  lesions  or 
pathological  conditions  of  the  urine  the  patient  is  unable  to  retain 
his  water  more  than  one  or  two  hours  at  a  time.  The  desire  to 
urinate,  if  not  immediately  gratified,  becomes  irresistible.  The  blad- 
der is  completely  emptied  at  each  act  of  micturition.  There  is  usually 
moderate  polyuria. 

This  condition  may  be  due.  to  masturbation,  may  follow  sexual 
excess  or  prolonged  sexual  excitement,  or  may  develop  without  ap- 
preciable cause.  It  usually  affects  young  unmarried  men.  In  the  cases 
we  have  observed  from  four  to  six  ounces  could  be  retained  comfort- 
ably ;  efforts  to  retain  more  than  this  caused  great  distress.  In  one 
case  between  seven  and  eight  ounces  of  clear  urine  of  low  specific 
gravity  (1010)  were  passed  every  one  and  a  half  to  two  hours  during 
the  day.  The  desire  to  urinate,  if  resisted,  caused  so  much  suffering 
that  the  patient  was  unable  to  attend  dinners  or  any  form  of  social 
entertainment  which  would  prevent  him  from  urinating  the  moment 
he  felt  this  inclination.  His  sleep  was  uninterrupted,  and  if  his  blad- 
der was  emptied  immediately  on  rising  he  experienced  no  distress, 
usually  passing  from  twelve  to  twenty  ounces. 

In  deciding  that  this  frequent  micturition  is  purely  functional  it 
must  be  remembered  that  a  similar  bladder-irritability  is  sometimes 
symptomatic  of  spinal  sclerosis,  particularly  that  form  associated 
with  exaggerated  reflexes :  hence  bladder-symptoms  should  always 
lead  to  an  investigation  as  to  the  condition  of  the  central  nervous 
system. 


292  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

A  bladder  abnormally  small  from  congenital  formation,  from 
long-continued  nocturnal  and  diurnal  incontinence,  or  from  cica- 
tricial contraction,  may  cause  a  form  of  frequent  urination  difficult  to 
distinguish  from  that  which  is  purely  functional.  The  frequency,  if 
due  to  contracted  bladder,  will  necessarily  be  both  nocturnal  and 
diurnal,  and  a  test  of  the  vesical  capacity  by  means  of  sterile  injec- 
tions will  demonstrate  the  nature  of  the  affection.  It  must  be  remem- 
bered that  the  frequency  of  polyuria  is  normal,  hence  the  quantity  of 
urine  which  the  patient  passes  must  be  known. 

The  treatment  of  this  purely  functional  frequency  is  at  first  mainly 
dietetic  and  hygienic.  Since  the  desire  is  often  not  felt  when  the 
mind  and  body  are  actively  engaged,  riding  the  bicycle  seems  particu- 
larly serviceable,  both  for  its  direct  effect  and  for  its  general  influence 
on  the  health.  All  causes  of  prostatic  congestion  or  hypersesthesia 
must  be  removed.  Sexual  excess,  prolonged  sexual  excitement,  and 
constipation  are  to  be  avoided  most  carefully.  Daily  cold  enemata 
of  salt  water  (a  drachm  to  the  pint)  are  serviceable  as  means  of 
emptying  the  lower  bowel.  Hemorrhoids  should  be  cured,  a  re- 
dundant foreskin  removed,  varicocele  relieved  by  a  suspensory  or 
subjected  to  radical  operation ;  in  fact,  every  possible  cause  of  reflex 
excitability  should  receive  attention. 

The  local  treatment  has  for  its  object  the  relief  of  hypersesthesia 
and  congestion  of  the  prostatic  urethra.  This  is  accomphshed  by 
full-sized  cold  steel  sounds,  the  direct  application  of  electricity,  instil- 
lations, rectal  irrigations,  applications  of  heat  or  cold,  and  prostatic 
massage.  The  details  of  these  methods  are  given  in  the  section  de- 
voted to  the  treatment  of  impotence. 

The  medicinal  treatment  should  be  confined  in  the  main  to  con- 
structives,  tonics,  and  stimulants.  Potassium  bromide  theoretically 
should  be  serviceable,  since  it  lessens  reflex  excitability.  We  have 
generally  found  it  useless.  Hyoscine  and  hyoscyamine  in  doses  of 
from  one  two-hundredth  to  one  one-hundredth  of  a  grain  thrice  daily, 
and  belladonna  suppositories,  each  containing  one-third  of  a  grain  of 
the  extract,  have  given  us  better  results  than  any  of  the  many  drugs 
commended. 

It  should  be  clearly  recognized  that  this  affection  when  it  has  been 
of  long  standing  is  extremely  obstinate  to  treatment,  and  that  cure,  if 
it  can  be  accomplished  at  all,  is  at  the  expense  of  months  of  patient, 
not  too  officious,  treatment.  Marriage,  with  its  consequent  regularity 
of  sexual  relations,  favorably  affects,  or  even  entirely  cures,  this  form 
of  frequent  urination. 

Frequent  urination  due  to  a  bladder  small  from  conformation  or 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINARY  TRACT.        293 

because  of  prolonged  non-retention  (habit  frequency)  is  best  treated 
by  daily  progressive  dilatation,  accomplished  by  means  of  a  fountain 
syringe,  elevated  three  feet  above  the  bladder,  and  a  short  urethral 
nozzle  or  soft  rubber  catheter.  The  urine  is  passed,  and  the  blad- 
der is  then  distended  with  warm  sterile  four  per  cent,  boric  acid  solu- 
tion till  further  injection  becomes  unbearable  to  the  patient.  The 
injected  liquid  is  allowed  to  flow  out  slowly,  and  the  distention  is 
repeated.  This  treatment  is  repeated  daily  or  every  second  day  till 
from  eight  to  twelve  ounces  of  urine  can  be  retained  comfortably. 

HydrauHc  distention  is  absolutely  inadmissible  when  the  bladder- 
cavity  is  lessened  because  of  tubercular  involvement. 

Alterations  in  the  Stream. — Urine  driven  by  a  healthy  bladder 
through  a  normal  urethra  should,  unaided  by  abdominal  strain,  flow 
from  the  meatus  in  a  steady  twisting  stream,  which,  if  it  be  directed 
horizontally  forward,  should  fall  from  three  to  five  feet  away  from  the 
vertical  hne  of  the  body.  When  the  muscular  walls  of  the  bladder  are 
weakened,  or  when  the  urethra  is  obstructed,  this  stream  is  neces- 
sarily altered  in  volume,  force,  and  direction.  Irregularity  in  mus- 
cular effort  or  sudden  blockage  of  the  urethra  breaks  the  continuity 
of  the  stream. 

A  small,  forked,  badly  aimed,  but  forcible  stream  points  to  narrow- 
ing at  or  near  the  meatus. 

A  forcible,  large  stream,  suddenly  and  for  a  time  permanently 
interrupted,  points  to  stone  or  other  foreign  body  in  the  urethra ;  a 
stream  becoming  slowly  smaller  and  less  forcible,  and  ultimately 
dropping  directly  down  from  the  end  of  the  penis,  points  to  enlarge- 
ment of  the  prostate  or  to  urethral  stricture  placed  far  back ;  it  also 
may  be  due  to  acute  congestion,  chronic  prostatitis,  atony  of  the 
bladder,  tumor-formation,  or  extra- urethral  pressure. 

A  stream  which  has  become  gradually  small  and  lacking  in  force, 
and  which  is  suddenly  arrested,  may  be  due  to  congested  stricture, 
congested  enlarged  prostate,  or  impacted  stone. 

A  fairly  forcible  stream  which  is  intermittently  and  irregularly 
stopped  for  a  moment  at  a  time — the  so-called  "  stuttering  urina- 
tion"— is  due  to  vesical  spasm,  and  is  either  a  neurosis  or  a  reflex. 

Suppression  of  urine  indicates  failure  of  excretion  from  the 
renal  tubules.  It  must  be  distinguished  from  retention  of  urine  in 
the  lower  urinary  tract,  though  such  retention  may  occasion  sup- 
pression. 

The  causes  of  suppression':  1.  Non-obstructive.     2.  Obstructive. 

Non-obstructive  suppression  develops  in  crippled  kidneys  second- 
ary to  trauma — even  when  trifling — of  the  genito-urinary  tract.     It 


294  v^ENITO-UEII^ARY    DISEASES   AND   SYPHILIS. 

may  follow  severe  systemic  injury  and  is  an  occasional  post-operative 
complication.  It  is  partly  reflex,  partly  toxic,  as  in  the  case  of  exten- 
sive burns  of  the  skin,  and  may  be  brought  about  by  the  passive  con- 
gestion incident  to  extreme  cardiac  weakness. 

The  symptoms  of  non-obstructive  suppression,  aside  from  the 
failure  to  pass  water  or  to  present  the  evidences  of  fluid  retained  in 
the  bladder  or  renal  pelves,  are  those  of  uraemia. 

Obstructive  suppression  is  that  associated  with  blocking  of  the 
ureters  or  of  the  vesical  outlet. 

The  symptoms  of  obstructive  anuria  may  be  veiled  by  an  accom- 
panying retention,  but  failure  of  further  excretion  on  relieving  the 
retention,  and  the  later  development  of  ureemic  symptoms  will  suffi- 
ciently mark  the  diagnosis. 

Treatment. — After  operations  on  the  genito-urinary  organs,  free 
diuresis  should  be  secured,  and  for  this  purpose  the  free  ingestion 
of  water,  enteroclysis,  and  hypodermoclysis  of  normal  salt  solution 
are  beneficial.  Circulatory  depression  is  benefited  by  strychnine, 
digitalis,  and  particularly  by  nitroglycerin,  the  relaxing  effect  of  the 
latter  being  distinctly  useful.  In  all  cases,  active  elimination  should 
be  secured  by  hot  packs,  vapor  baths,  in  some  cases  by  pilocarpin  hy- 
podermically,  and  by  free  purgation  by  calomel  and  the  saline  cathar- 
tics. In  the  common  form  of  suppression  due  to  reflex  sympathetic 
causes,  hot  poultices,  cupping,  and  other  counter-irritants  are  useful, 
and  it  is  here  that  high  hot  injections  of  salt  solution  into  the  colon 
are  doubly  indicated.  If  shock  be  the  cause,  adrenalin  chloride  intra- 
venously with  strychnine  and  atropine  hypodermically  are  indicated. 

The  various  operative  procedures  which  have  been  beneficial  for 
suppression  jjer  se,  aside  from  those  directed  to  its  cause,  are  simple 
puncture,  splitting  the  capsule,  incisions  into  the  capsule,  decapsula- 
tion, and  nephrotomy.  These  operations  (described  elsewhere)  should 
not  be  done  until  other  measures  have  failed,  nor  should  they  be  post- 
poned until  the  patient  becomes  apparently  moribund,  though  even 
then  they  have  been  successful.  Operative  measures  are  indicated 
if  three  days  of  conservative  treatment  have  proven  futile,  though 
cases  cured  after  eight  days  are  reported.  A  local  cause,  such  as 
a  blocking  calculus,  should  be  suspected  in  the  absence  of  a  preceding 
history  of  chronic  renal  degeneration. 

Retention  of  Urine. ^ — Retention  implies  inability  to  empty  the 
bladder.  This  may  be  due  to  atony  or  paralysis  of  the.  detrusor 
muscles,  to  reflex  spasmodic  action  of  the  sphincters,  or  to  obstruc- 
tion at  the  neck  of  the  bladder  or  in  the  urethra. 

Locomotor  ataxia,  Pott's  disease,  general  palsies,  sclerosis,  and 


SYMPTOMATOLOGY  OF  DISEASES  OF  UEINAKY  TKACT.        295 

severe  cerebro-spinal  injuries  may,  by  interference  with  the  vesical 
centre  of  the  cord,  occasion  paralytic  retention.  The  muscles  may 
be  directly  paralyzed  by  over-clistention,  by  inflammation  extending 
from  the  mucous  coat  or  from  the  peritoneal  investment,  as  in  peri- 
tonitis, or  as  the  result  of  degeneration  consecjuent  upon  prolonged 
exhausting  diseases. 

Spasmodic  retention  may  follow  shock  or  injury,  operations  upon 
the  spermatic  cord,  the  rectum,  or  the  testicles,  or  prolonged  volun- 
tary retention.  Obstruction  at  the  vesical  orifice  may  be  due  to 
tumor,  impacted  stone,  clot,  foreign  body,  or  prostatic  hypertrophy. 

Retention  may  be  of  sudden  or  of  gradual  onset,  and  may  be 
partial  or  complete. 

The  retention  of  sudden  onset  is  typified  by  that  observed  in  cases 
of  rupture  of  the  urethra,  or  of  impacted  stone,  or  of  reflex  spasm 
following  operations  on  the  anus.  The  symptoms  are  pains  felt  in  the 
region  of  the  bladder  and  steadily  increasing  in  intensity,  recurrent 
unavailing  efforts  at  micturition  with  a  constant  torturing  desire,  ex- 
treme tenderness  over  the  region  of  the  bladder,  and  the  formation  of 
a  distinct  tumor,  dull  on  percussion,  globular  in  shape,  and  sometimes 
extending  as  high  as  the  umbilicus.  Rectal  and  suprapubic  palpation 
show  that  this  tumor  is  fluctuating,  and  that  it  occupies  the  position 
of  the  distended  bladder.  The  final  proof  is  afforded  by  catheteri- 
zation. 

Gradual  retention  may  develop  so  insidiously  that  it  is  not 
suspected  until  direct  examination  shows  the  presence  of  bladder- 
distention.  Urethral  stricture,  lesions  of  the  cord,  intracystic  and 
extracystic  bladder-growths  or  inflammations,  enlargement  of  the 
prostate,  and  atrophy  of  the  detrusor  muscles  are  common  causes  of 
this  form  of  retention.  The  early  symptom  is  frec|uent  micturition, 
the  stream  passing  with  little  force  and  often  with  much  diminished 
volume.  This  frequency  is  due  to  the  fact  that  the  bladder  is  unable 
to  empty  itself  entirely,  a  certain  amount  of  residual  urine  remaining. 

Even  when  the  vesical  muscles  are  healthy,  if  the  flow  of  urine  is 
so  obstructed  that  the  time  required  to  empty  the  bladder  is  unduly 
prolonged,  the  involuntary  detrusor  muscles,  becoming  tired,  relax 
before  the  bladder  is  thoroughly  -empty,  thus  allowing  a  certain 
amount  of  residual  urine.  This  residual  urine  is  proportionate  in 
quantity  to  the  degree  of  obstruction  encountered  in  the  urethra 
and  to  the  loss  of  tone  of  the  bladder-muscles.  When  sterile  and 
moderate  in  amount  the  only  symptom  it  causes  is  increased  fre- 
quency of  urination.  The  reason  for  this  is  obvious  :  if  the  bladder 
cannot  hold  more  than  ten  ounces  comfortably,  and  if,  when  it  is  full, 


296  GENITO-UEINAEY    DISEASES   AND   SYPHILIS. 

an  unsuccessful  effort  is  made  to  empty  it,  five  ounces  remaining, 
the  desire  to  urinate  will  again  occur  when  five  more  ounces  have 
been  secreted  by  the  kidneys,  since  the  bladder  will  then  contain 
ten  ounces.  Its  capacity  as  a  receiver  of  urine  from  the  kidneys  is 
lessened  proportionately  to  the  amount  of  residual  urine  it  contains. 

When  the  retained  urine  exceeds  four  to  six  ounces,  because  of 
the  frequent  urinations  and  the  more  or  less  sustained  tension,  there 
develops  a  certain  degree  of  chronic  congestion  of  the  bladder,  which 
is  often  markedly  increased  by  cystitis  and  fermentation  of  the  stag- 
nant urine. 

As  the  obstruction  gradually  increases,  and  as  the  muscles  become 
atonic  or  atrophic  from  congestion,  inflammation,  and  overstretching, 

Fig.  100. 


Tumor  formed  by  the  distended  bladder.    Gradual  distention  from  hypertrophied  prostate. 

the  bladder  is  more  and  more  dilated,  until,  finally,  it  may  reacJi 
enormous  proportions.  When  this  gradual  retention  occurs  in  the 
course  of  fevers, — typhoid,  for  instance, — it  is  probably  due  to  de- 
generation of  the  detrusor  muscles  and  to  abolition  of  the  normal 
reflex.  The  bladder  may  then  slowly  distend,  giving  rise  to  no 
symptoms  other  than  apparent  incontinence,  the  sphincter  muscle 
yielding  when  the  intravesical  tension  becomes  sufficiently  high  and 
allowing  the  urine  to  trickle  slowly  away.  The  same  gradual  unsus- 
pected distention  develops  in  chronic  prostatic  overgrowth,  the  symp- 
toms suggesting  incontinence  rather  than  retention,  and  the  true 
condition  not  being  suspected  till  inspection  or  palpation  shows  a 


SYMPTOMATOLOGY  OF  DISEASES  OF  TKINAKY  TKACT.       297 

hypogastric  tumor.  The  appearance  of  this  tumor  is  seen  in  Fig.  100. 
The  patient  from  whom  this  photograph  was  taken  complained  of 
urinary  incontinence,  and  was  brought  by  his  pliysician  because  of  a 
supposed  sohd  growth  in  the  liypogastric  region.  Bimanual  palpation 
at  once  proved  that  this  mass  was  the  distended  bladder. 

When  associated  with  fevers,  and,  indeed,  under  all  circumstances, 
incontinence  of  urine  should  lead  to  careful  examination  for  an  over- 
distended  bladder. 

When  the  bladder  is  able  to  empty  itself  partially,  the  retention  is 
incomplete.  When  no  urine  can  be  passed,  it  is  complete.  In  either 
case  there  results  an  abnormal  intravesical  tension,  intermittent  when 
the  function  of  micturition  is  not  entirely  suppressed,  continuous  and 
steadily  increasing  in  case  of  complete  retention. 

The  Effects  of  Retention. — Guyon  and  Albarran  have  shown 
experimentally  that  even  a  moderate  amount  of  retention  causes  dis- 
tinct vesical  congestion,  followed,  if  the  retention  is  not  relieved,  by 
ecchymoses,  bloody  extravasation,  involving  the  whole  thickness  of 
the  bladder- walls,  and  pronounced  epithelial  desquamation.  The 
ureters  and  the  kidney  pelves  and  tubules  show  the  same  changes, 
— i.e.,  intense  congestion  and  parenchymatous  ecchymoses  and  epi- 
thelial degeneration  and  shedding.  The  peritoneum  overlying  the 
bladder  is  often  congested  and  ecchymotic,  and  the  intesj^ines  and 
abdominal  viscera  participate  in  the  general  vascular  engorgement. 
Ultimately  the  bladder  ruptures  into  the  peritoneal  cavity. 

As  a  result  of  over-distention  the  detrusor  muscles  of  the  bladder 
are  paralyzed,  remaining  absolutely  flaccid,  even  though  the  urine  be 
drawn.  The  desquamation  of  the  stratified  pavement  epithelium, 
which  when  normal  and  unbroken  prevents  absorption  from  the 
bladder,  exposes  the  lymph-  and  blood-channels,  thus  allowing  toxic 
substances  and  micro-organisms  contained  in  the  urine  to  poison  the 
system.  When  the  vesical  tension  is  very  pronounced,  the  down- 
ward current  of  urine  passing  from  the  kidneys  to  the  bladder  ceases, 
and,  if  there  is  concomitant  infection,  this  will  rapidly  reach  the  kid- 
ney pelvis  by  way  of  the  ureter,  though  reversed  peristalsis  or  back- 
ward regurgitation  as  the  result  of  vesical  tension  has  not  been 
shown  experimentally.  Ultimately  the  sphincter  muscle  at  the  vesi- 
cal orifice  of  the  ureter  becomes  insufficient,  since  even  inert  bodies, 
such  as  powdered  charcoal,  will,  if  injected  into  the  bladder,  ascend 
in  small  quantities  into  the  kidney  pelves. 

Death  results  from  uraemia  ;  very  exceptionally  in  men  from  rup- 
ture. The  temperature  in  the  absence  of  infection  is  normal  or  sub- 
normal.    The  extent  and  severity  of  the  lesions  just  described  are 


298  gejStito-urinary  diseases  and  syphilis. 

dependent  on  the  degree  of  vesical  distention,  and  this  in  turn  is  pro- 
portionate to  the  duration  of  the  complete  retention  and  the  quantity 
of  urine  secreted. 

As  a  result  of  experimental  research  and  clinical  study,  the  im- 
mediate effects  of  extreme  acute  distention  of  the  bladder  may  be 
summarized  as  follows.  The  bladder,  prostate,  ureters,  and  kidneys 
are  enormously  congested.  The  muscles  of  the  bladder  become  in- 
sufficient, and  their  fasciculi  are  often  mechanically  separated  by 
the  distention,  producing  the  ribbed  or  trabeculated  bladder.  The 
kidneys,  at  first  excited  to  increased  activity,  as  pressure  increases 
secrete  slowly  or  not  at  all.  The  whole  urinary  tract  is  ripe  for 
infection,  and  absorption  from  this  tract  takes  place  readily. 

If  micro-organisms  are  introduced  into  the  bladder  they  very 
rapidly  produce  cystitis  and  quickly  reach  the  kidneys.  The  intro- 
duction of  similar  organisms  into  the  healthy  bladder  is  without  evil 
effect,  since  the  flat  epithelium  prevents  their  entrance  into  the  tis- 
sues, and  the  intermittent  stream  of  water  from  the  ureters  keeps 
them  from  ascending  along  these  channels. 

Chronic  retention  produces  pathological  alterations  which  are  less 
immediately  threatening  than  those  of  acute  retention.  There  is 
chronic  congestion  of  the  entire  urinary  apparatus,  with  pronounced 
susceptibility  to  infection.  When  the  retention  is  moderate  and  in- 
complete these  changes  are  limited  solely  to  the  bladder,  since  the 
ureters  and  kidneys  are  reached  only  when  vesical  tension  has  been 
extreme. 

The  first  effect  of  increased  vesical  tension  on  the  kidneys  is  the 
marked  increase  in  secretion,  due  in  part  to  bladder  irritation,  prob- 
ably in  the  main  to  congestion.  Later  the  urine  is  diminished  in 
quantity.  Exceptionally,  after  relief  of  tension,  anuria  develops  ;  more 
frequently  there  is  pronounced  polyuria. 

The  fever,  if  it  develops,  is  nearly  always  due  to  concomitant  in- 
fection, and  not  to  retention  itself.  The  tem^Dcrature  is  normal  or 
subnormal  in  both  acute  and  chronic  retention. 

Although  the  immediate  effects  of  chronic  retention,  the  use  of  the 
term  chronic  necessarily  implying  that  the  retention  is  incomplete,  are 
less  serious  than  those  of  acute  retention,  the  ultimate  results,  are 
equally  disastrous,  the  bladder  dilating  and  losing  tonicity,  and  the 
ureters,  kidney  pelves,  and  kidneys  becoming  involved. 

The  bladder  muscle  may  be  completely  and  permanently  para- 
lyzed, or,  where  the  retention  is  partial,  particularly  in  case  of 
stricture,  it  may  be  greatly  hypertrophied.  This  hypertrophy  is 
none  the  less  followed  by  dilatation  of  the  ureters  and  their  pelves 


SYMPTOMATOLOGY  OF  DISEASES  OP  UKINAKY  TRACT.        299 


and   profound   alterations   in   the    structure    of  the   kidneys.      (Fig, 
101.) 

The  general  treatment  of  acute  and  of  chronic  retention  calls  for 
relief  of  tension  as  soon  as  possible,  and  the  observance  of  rigorous 
antiseptic  precautions  in  the  use  of  the  catheter.  Sudden  evacu- 
ation of  the  bladder  in  cases  of  chronic  retention  often  occasions 
bleeding  not  only  from  the 
bladder,  but  also  from  the 
kidneys  and  into  the  sub- 
stance of  these  organs.  This 
is  less  liable  to  occur  Avhen 
the  urine  of  acute  reten- 
tion is  drawn.  It  is  due 
to  the  rapid  diminution  of 
pressure  to  which  engorged 
vessels  have  long  become 
accustomed.  The  renal  con- 
gestion is  often  evinced  by 
blood-casts. 

Exceptionally,  after  the 
first  evacuation  there  may 
be  such  marked  relief  of 
congestion  that  the  power 
of  micturition  is  restored. 
Usually  catheterization  must 
be  employed  for  some  time. 
Where  there  is  polyuria— 
and  this  is  frequently  the 
case — it  is  important  to 
catheterize  tlie  bladder  Ire- 
cjuently.  This  manipula- 
tion may  have  to  be  re- 
peated every  two  hours. 
The  intervals  should  bo 
such  that  not  more  than  eight  to  twelve  ounces  shall  accumulate 
before  being  drawn. 

From  an  etiological  stand-point  retention  of  urine  may  be  classified 
as  follows : 

1.  Retention  due  to  paresis  or  incoordination  of  the  bladder  muscles. 

2.  Retention  from  congestion  or  acute  inflammation.  ' 

3.  Retention  due  to  blocking  of  the  urethra  by  clots,  foreign  body, 
stone,  or  portions  of  new  growth. 


Hypertropliied  bladder  from  urethral  stricture, 
tion  of  ureters  and  kidney  pelves. 


Dilata- 


300  GENITO-URIlSrARY   DISEASES   AND   SYPHILIS. 

4.  Retention  caused  by  prostatic  enlargement. 

5.  Retention  caused  by  stricture. 

6.  Retention  due  to  traumatism. 

1.  Retention  of  Urine  due  to  Paresis  or  Incoordination  of  the 
Bladder  Muscles. — Under  this  heading  are  classed  those  cases  in 
which  narrowing  or  pathological  alteration  of  the  channel  of  exit  for 
the  urine  plays  no  part.  There  is  no  preceding  history  suggesting 
urethral  stricture  or  prostatic  enlargement.  The  cause  of  retention  is 
either  failure  of  detrusor  power  or  loss  of  control  over  the  sphincters, 
these  not  relaxing  as  they  normally  should  when  the  detrusors  con- 
tract. This  form  of  retention  is  common  in  cerebral  injury,  in  hemi- 
plegia, in  paraplegia,  in  spinal  injury  or  disease,  in  Pott's  disease,  and 
in  spinal  ataxias.  In  ataxic  cases  the  retention  may  be  from  sensory 
failure,  the  patient  not  perceiving  when  the  bladder  is  full ;  a  catheter 
must  then  be  used  not  according  to  a  feehng  of  vesical  repletion,  but 
at  certain  definite  times. 

The  retention  sometimes  observed  in  shock,  hysteria,  peritonitis, 
paravesical  inflammation,  exhausting  diseases,  neurasthenia,  and  vol- 
untary postponement  of  the  act  of  micturition  may  be  partly  spas- 
modic, but  is  probably  due  in  the  main  to  muscular  atony  and  dis- 
ordered reflex  action.  Retention  following  operations  about  the  anus 
or  complicating  a  full  rectum  is  usually  spasmodic,  the  sphincter 
being  excited  to  undue  irritability  not  only  by  the  nervous  reflex,  but 
also  by  the  vascular  engorgement  consequent  on  these  operations. 

Symptoms. — Retention,  whatever  be  its  cause,  is  characterized  by 
the  same  symptom, — i.e.,  the  formation  of  a  fluctuating  tumor  in  the 
bladder  region.  In  cases  of  paraplegia  or  abolition  of  sensibility  the 
pain  and  frequent  efforts  at  urination  are  wanting.  Under  other  cir- 
cumstances, if  the  retention  has  been  of  sudden  onset,  the  distress  it 
occasions  is  characteristic  and  unmistakable.  Since  the  urethra  is 
patulous,  there  develops,  usually  before  there  is  much  back  pressure 
exerted  in  the  direction  of  the  kidneys,  a  dribbling  of  urine,  the  in- 
continence of  retention,  which  is  misleading.  A  patient  who  com- 
plains of  incontinence  should  always  be  examined  for  retention. 

Diagnosis. — The  probable  absence  of  urethral  or  prostatic  ob- 
struction will  be  founded  on  the  patient's  previous  history,  or,  if  this 
is  unobtainable,  urethral  exploration  will  show  that  the  way  to  the 
bladder  is  unobstructed.  Spasm  of  the  compressor  urethrEe  may 
be  misleading,  but  this  yields  completely  to  the  gentle  steady  pressure 
of  a  steel  sound. 

When  -  retention  develops  without  apparent  cause  in  a  person 
who  gives  no  previous  history  of  urethral  or  bladder  trouble,  the 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINARY  TPvACT.        301 

neuropathies  must  be  suspected,  and  search  should  be  made  for  cor- 
roborative signs  of  ataxia. 

D^eatment. — Retention  which  is  a  local  expression  of  hysteria  or 
neurasthenia  is  usually  relieved  promptly  by  a  hot-water  enema 
(103°  F.),  followed  by  a  hot  sitz-bath  or  general  bath.  The  patient 
is  directed  to  pass  the  enema  while  still  in  the  bath,  and  usually 
will  urinate  without  difficulty  during  the  act  of  defecation.  This 
treatment  is  efficient  in  retention  from  constipation,  anal  operations, 
inflammation,  shock,  or  prolonged  voluntary  retention. 

When  the  hot  enema  and  bath  fail,  or  if  these  cannot  be  applied, 
catheterization  is  indicated.  This  must  be  practised  with  precisely  the 
same  care  as  would  be  exercised  by  the  surgeon  were  he  about  to 
perform  a  major  operation,  since  it  has  been  shown  that,  from  the 
intense  congestion  which  always  accompanies  retention,  the  bladder 
is  peculiarly  vulnerable  to  sepsis  and  the  kidneys  are  ripe  for  an 
ascending  infection. 

The  evacuating  instrument,  preferably  a  soft  rubber  catheter,  about 
No,  16  F.,  is  lubricated,  introduced  as  far  as  the  membranous  urethra, 
and  attached  to  an  irrigating-bag  containing  a  hot  dilute  antiseptic  solu- 
tion (1  to  20,000  bichloride).  A  half-pint  of  this  solution  is  allowed 
to  flow  through  the  catheter,  thoroughly  irrigating  the  anterior  urethra : 
the  irrigating-bag  is  then  disconnected,  and  the  catheter  is  passed  into 
the  bladder. 

When  retention  has  been  chronic  and  progressive,  and  particularly 
when  there  is  also  infection,  the  sudden  emptying  of  the  bladder  is 
liable  to  be  followed  by  severe  hemorrhage,  which,  involving  the  kid- 
neys and  their  pelves,  may  result  in  partial  or  complete  suppression 
of  urine  and  may  prove  fatal. 

When  retention  is  due  to  a  central  nerve  lesion,  as  in  Pott's  dis- 
ease, trauma,  or  ataxia,  or  to  muscular  degeneration,  as  in  typhoid 
fever  or  in  arteriosclerosis,  regular  aseptic  catheterization  must  be 
practised  as  frequently  as  is  required  to  prevent  abnormal  vesical 
tension.  If  at  any  time  more  than  twelve  ounces  are  drawn,  this 
indicates  that  the  intervals  between  instrumentation  are  too  long. 
Practised  with  due  attention  to  cleanliness,  these  catheterizations  pre- 
vent cystitis,  since  they  relieve  the  venous  engorgement,  which  is  the 
most  potent  predisposing  factor  to  infection. 

In  all  these  cases  urinary  antiseptics  should  be  administered  by 
the  mouth,  and  careful  attention  should  be  given  to  the  diet  and  to 
general  hygiene. 

2.  Retention  of  Urine  from  Congestion  or  Acute  Inflammation. — 
When,  as  the  result  of  a  severe  gonorrhoea,  an  irritating  injection, 


302  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

rough  sounding,  or  a  prostatic  abscess,  retention  develops,  this  may 
be  due  partly  to  blocking  of  the  urethra  by  inflammatory  swelling, 
partly  to  spasm.  In  the  vast  majority  of  cases  neither  spasm  nor 
acute  urethritis  is  competent  to  cause  complete  retention.  When  this 
develops  there  is  usually  a  pre-existing  lesion,  such  as  stricture  of  large 
calibre,  chronic  prostatitis  with  sclerosis  and  contracture  of  the  in- 
ternal vesical  sphincter,  or  moderate  prostatic  enlargement,  not  suffi- 
ciently obstructive  in  the  absence  of  acute  inflammation  to  cause  even 
partial  retention. 

Symptoms. — Aside  from  the  characteristic  symptoms  of  retention, 
the  determination  of  the  cause  of  this  condition  will  depend  in  the 
main  upon  the  preceding  history.  If  symptoms  of  enlarged  prostate 
or  of  long-standing  gleet  are  absent,  and  if  in  the  course  of  an  acute 
gonorrhoea,  for  instance,  retention  develops,  the  cause  of  this  must  be 
looked  for  either  in  the  urethra — usually  in  its  membranous  part — 
or  in  the  prostate.  Before  exploring  the  urethra  the  prostate  should 
be  palpated  per  rectum ;  if  this  is  normal  in  size  and  non-sensitive, 
urethral  inflammation  and  spasm  may  be  suspected  as  the  cause  of 
retention.  In  this  case  the  hot  bath  and  hot  enema  are  indicated, 
since  instrumentation  should  be  avoided  because  of  the  danger  of  in- 
fecting the  bladder.  If  these  measures,  reinforced  by  opium  supposi- 
tories or  morphine  injections,  prove  useless,  a  woven  coude  catheter 
should  be  passed,  since  the  urethral  spasm  is  so  tight  that  it  effectively 
resists  the  softer  instrument.  This  causes  such  agonizing  pain  that  it 
is  well  to  administer  ether  to  the  first  stage  each  time  it  is  used.  It 
should  be  preceded  by  urethral  irrigation,  and  should  be  withdrawn 
while  an  antiseptic  solution  is  flowing  through  it. 

When  the  prostate  felt  through  the  rectum  is  large,  hot,  and 
tender,  recourse  may  be  had  to  hot  baths,  enemas,  and  opium,  but 
there  is  little  hope  of  relieving  vesical  tension  by  these  means  unless 
the  swelling  is  purely  congestive.  In  that  case  it  should  subside 
promptly  under  treatment,  and  palliative  measures  should  be  efficient. 
Should  they  fail,  the  catheter  must  be  used  without  delay,  not  only 
for  immediate  relief,  but  also  because  by  regularly  emptying  the 
bladder  this  viscus  is  less  likely  to  become  infected.  The  prostatic 
abscess  should  be  opened  as  soon  as  it  is  detected,  preferably  through 
the  perineum. 

3.  Retention  of  Urine  from  Sudden  Blocking  of  the  Urethra  or 
THE  Vesical  Neck. — This  form  of  retention  may  be  due  to  the  lodge- 
ment of  a  stone  or  foreign  body  in  the  urethra,  to  a  pedunculated 
bladder-tumor  situated  near  the  neck  of  the  bladder  and  acting  as  a 
ball-valve,  or  to  blood-clots  sufficiently  firm  to  plug  the  vesical  orifice. 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINARY  TRACT.        303 

Urethral  calculi  and  foreign  bodies  have  been  considered  in  an- 
other part  of  this  work. 

Blood-clots  rarely  cause  retention  when  the  urethra  is  unob- 
structed. They  are  liable  to  cause  intermittent  blocking  of  the 
urethra,  but  are  ultimately  expelled.  In  cases  of  prostatic  hyper- 
trophy or  stricture,  clots  may  cause  absolute  retention  and  may 
seriously  interfere  with  catheterization. 

Symptoms. — Retention  of  urine  from  vesical  clots  will  give  no  char- 
acteristic symptoms  other  than  those  of  sudden  retention.  Bloody 
urine  containing  small  clots  may  have  been  passed  before  the  reten- 
tion develops.  There  is  a  history  of  previous  hemorrhage,  or  there 
is  a  sufficient  cause,  such  as  traumatism,  for  extravasation  of  blood. 
The  catheter  enters  the  bladder  readily,  and,  even  though  it  is  almost 
immediately  blocked  by  a  clot,  draws  some  bloody  urine  ;  suction  by 
a  syringe  draws  out  fragments  of  clot  and  allows  the  urine  to  flow. 

When  the  retention  is  due  to  a  pedunculated  tumor  or  a  small 
movable  calculus,  the  symptoms  may  be  precisely  the  same  as  those 
which  characterize  retention  from  clot,  since  there  are  likely  to  be 
haematuria  and  sudden  stoppage  of  the  stream  of  urine.  If,  however, 
the  catheter  is  passed  well  within  the  bladder,  its  eye  is  not  blocked 
and  the  urine  flows  freely. 

Diagnosis.— In  deciding  whether  retention  is  due  to  blood-clot, 
small,  movable  sione,  or  pedunculated  tumor,  the  history  of  the 
case  and  the  course  of  the  symptoms  will  usually  lead  to  a  cor- 
rect opinion.  Thus,  stone  is  preceded  by  renal  cohc,  by  frequency 
of  urination,  and  by  pain  felt  just  behind  the  meatus  at  the  end  of 
the  act.  When  it  is  displaced  ft'om  the  neck  of  the  bladder  by  a  metal 
catheter  a  characteristic  grating  may  be  felt.  The  urine  which  is 
drawn  contains  but  little  blood. 

A  pedunculated  vesical  tumor  may  cause  an  obstruction  which 
readily  yields  to  the  catheter  and  which  bleeds  freely.  The  nature 
of  the  obstruction  would  be  open  to  suspicion  if,  in  the  absence  of 
symptoms  of  stone,  the  patient  complained  of  occasional  apparently 
causeless  profuse  haematuria ;  if  on  the  relief  of  retention  no  clots 
were  drawn,  the  urine  flowing  freely  as  soon  as  the  eye  of  the  cath- 
eter reached  the  bladder;  and  if  urination  in  the  dorsal  decubitus 
prevented  the  stoppage  of  the  stream.  Finally,  cystoscopic  examina- 
tion should  definitely  settle  the  matter. 

Treatment. — Retention  from  blood-clot  does  not  necessarily  call 
for  immediate  catheterization,  since,  provided  there  is  no  urethral 
obstruction,  as  the  clot  softens  and  disintegrates  it  is  passed  sponta- 
neously ;  indeed,  it  is  more  likely  to  escape  through  the  natural  pas- 


304  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

sage  than  through  a  medium-sized  catheter.  A  hot  bath  and  an 
opium  suppository  or  a  morphine  injection  to  relieve  the  associated 
spasm  of  the  sphincters,  and  efforts  at  urination  made  with  the  pa- 
tient in  the  dorsal  decubitus  and  with  the  pelvis  elevated,  usually 
result  in  relief. 

Should  these  measures  fail,  the  patient  is  placed  on  his  back  with 
the  pelvis  elevated,  and  a  large  woven  catheter  is  passed  till  its  eye  is 
just  within  the  internal  vesical  sphincter.  This  decubitus  favors 
gravitation  of  the  clots  to  the  upper  posterior  portion  of  the  bladder, 
where  they  are  less  likely  to  block  the  catheter  before  the  main  bulk 
of  the  urine  has  been  drawn  off. 

When  the  catheter  becomes  obstructed  from  lodgement  of  a  clot  in 
its  eye,  a  drachm  of  dilute  antiseptic  solution  should  be  injected  forci- 
bly. If  after  several  repetitions  of  this  manoeuvre  it  is  apparent  that 
the  catheter  cannot  be  kept  clear  long  enough  to  allow  the  urine  to 
flow  in  sufficient  quantity  to  relieve  tension,  an  eight-ounce  hard 
rubber  syringe,  with  a  piston  which  fits  accurately,  should  be  at- 
tached to  the  end  of  the  catheter  and  the  clots  should  be  sucked  out. 
Should  this  method  fail,  a  large  evacuating  litholapaxy-tube  should 
be  passed,  and  through  it  the  blood  should  be  aspirated. 

If  because  of  a  large  prostate  the  evacuating  tube  cannot  be  passed, 
either  perineal  or  suprapubic  cystotomy  is  indicated,  in  accordance 
with  the  cause  of  the  bleeding.  In  any  event  the  retention  must  be 
relieved  and  the  bladder  freed  of  clots,  since  the  presence  of  blood 
in  the  urine  markedly  favors  the  development  of  cystitis.  Emptying 
the  bladder  is  the  most  efficient  means  of  stopping  further  bleeding 
if  this  is  of  cystic  origin. 

Retention  due  to  a  pedunculated  cystic  tumor  can  be  relieved  by 
catheterization,  the  instrument  pushing  aside  the  growth  and  prevent- 
ing it  from  acting  as  a  plug.  The  same  treatment  is  appropriate  to 
calculus  lodged  in  the  vesical  neck. 

RETENTION  OF  URINE  FROM  PROSTATIC  ENLARGEMENT. 
Of  all  forms  of  urinary  retention  that  due  to  hypertrophied  pros- 
tate is  the  most  frequent.  This  complication  of  hypertrophy  is 
infinitely  more  serious  than  the  disease  which  causes  it.  It  is  due  to 
the  increased  resistance  to  the  escape  of  urine  offei'ed  by  alterations  of 
the  bladder-neck,  elongation  and  deflection  of  the  prostatic  urethra, 
diminution  in  the  calibre  of  the  latter,  and  vesical  atony.  The  wafls 
of  the  vesical  orifice  are  thickened,  and  the  opening  is  raised  above  the 
level  of  the  bas-fond,  thus  leaving  a  pouch.  The  overgrowth  may  in- 
volve one  or  all  of  the  prostatic  lobes ;  usually  the  entire  prostate  is 


Fig.  103. 


Hypertrophy  of  the  lateral  lobes  of  the  prostate.    (Watson.) 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINAEY  TRACT. 


305 


enlarged.  (Fig,  102.)  From  overgrowth  of  the  middle  lobe  more  or 
less  of  a  projection  is  formed  at  the  vesical  orifice.  The  enlarged 
lateral  lobes  narrow  the  urethra  and  force  it  to  one  side  or  the  other, 
in  accordance  with  the  position  of  greatest  overgrowth,  (Fig,  103.)  As 
a  result  of  this  obstruction  the  bladder-muscles  become  weakened, 
at  least  so  far  as  their  propulsive  power  is   concerned.     There  is 

Fig,  102. 


Hypertrophy  of  the  lateral  and  median  lobes  of  the  prostate.    (Watson.) 

always  very  marked  hypertrophy  of  individual  fibres  or  fasciculi, 
forming  prominent  ridges.  The  general  symmetrical  hypertrophy  so 
frequently  observed  in  partial  retention  following  stricture  is  rarely 
found  when  obstruction  is  due  to  prostatic  hypertrophy.  Vesical 
inertia  is  also  encouraged  by  muscular  degeneration  incident  to  ather- 
oma, which  so  often  complicates  enlarged  proslate,  cystitis,  prolonged 
venous  congestion,  and  over-distention, 

20 


306  GEXITO-UKINART   DISEASES    AND   SYPHILIS. 

As  a  result  of  overgrowth  the  prostatic  urethra  may  be  double 
or  even  triple  its  normal  length.  The  vesical  orifice  and  prostatic 
urethra  are  encroached  upon  at  the  expense  of  the  lower  and  lateral 
walls.  The  superior  wall  preserves  its  normal  direction.  This  fact 
is  important  as  bearing  upon  the  proper  use  of  catheters  for  the 
rehef  of  retention. 

The  prostate  may  be  tough  and  fibrous,  presenting  an  obstacle 
which  will  yield  only  to  rigid  instruments,  or  may  be  so  friable  that  it 
is  bruised  and  lacerated  by  even  soft  rubber  catheters  or  exploring 
bougies.  Its  dimensions  as  felt  by  the  rectum  do  not  necessarily 
indicate  the  degree  of  urethral  obstruction  it  occasions. 

Symjjtoms. — During  the  earliest  stages  of  prostatic  enlargement  no 
symptoms  are  excited  upon  the  part  of  the  bladder ;  as  the  growth 
increases,  elevating  the  internal  vesical  orifice,  there  is  partial  reten- 
tion, a  certain  amount  of  residual  urine  remaining  after  each  micturi- 
tion. This,  if  it  is  sterile  and  does  not  exceed  four  to  six  ounces, 
causes  no  symptoms  other  than  a  slight  increase  in  frequency  of 
urination  and  a  habit  of  rising  once  in  the  early  morning  hours  to 
empty  the  bladder. 

As  the  obstruction  becomes  more  pronounced,  residual  urine  in- 
creases in  amount,  the  desire  to  urinate  comes  more  frequently  and 
is  more  imperative,  especially  at  night,  there  is  usually  slowness  in 
starting  the  stream,  and  this  is  projected  with  less  force.  Finally, 
there  is  distinct  vesical  atony,  the  walls  of  the  bladder  yield  to  the 
slowly  increasing  tension,  and  that  viscus  becomes  greatly  dilated, 
sometimes  extending  above  the  umbilicus.  This  dilatation  involves 
the  ureters  and  the  kidney  pelves.  The  secreting  portion  of  the 
kidney  becomes  insufficient,  a  condition  of  uremia  develops,  char- 
acterized by  gastro-intestinal  disorders  and  steady  deterioration  in 
health,  and  death  ensues.  When  the  bladder  reaches  an  extreme 
degree  of  distention  there  is  a  constant  dribbling  of  urine.  It  should  be 
noted  that  this  train  of  pathological  changes  may  be  evolved  without 
the  patient  having  the  faintest  conception  that  there  is  a  condition  of 
vesical  tension,  the  symptoms  of  which  he  complains  being  simply 
frequent  micturition,  especially  aggravated  at  night,  often  attributed 
to  polyuria,  and  ultimately  followed,  by  incontinence  of  urine,  diffi- 
culty in  s4:arting  the  stream  and  loss  in  its  force,  and  apparently 
causeless  digestive  troubles.  Should  cystitis  intervene,  the  vesical 
sympto-ms  become  so  marked  that  they  will  scarcely  be  overlooked. 
There  are  then  pain,  tenesmus,  and  all  the  phenomena  of  bladder- 
inflammation  aggravated  by  the  retention. 

If,  in  the  course  of  chronic  incomplete  retention,  the  enlarged 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINARY  TRACT.        307 


prostate  becomes  suddenly  congested  from  infection,  exposure,  sexual 
excesses,  indiscretion  in  diet,  or  other  sufficient  cause,  ttiere  will  result 
acute  retention,  characterized  by  restlessness,  pain  in  the  bladder,  and 
futile  efforts  at  micturition.  This  acute  retention  is  often  not  com- 
plete, the  patient  being  able  to  pass  a  portion  of  his  water,  but  only 
after  violent  straining. 

Diagnosis. — Retention  due  to  prostatic  enlargement  is  observed  in 
men  past  middle  age.  There  is  a  history  of  frequent  urination,  be- 
ginning with  night  rising  and  slowly  becoming  more  marked.  Until 
an  extreme  degree  of  tension  is  reached,  this  frequency  is  always 
most  marked  in  the  night  or  early  morning.  Rectal  examination 
shows  an  enlarged  prostate,  and  rectal  and  suprapubic  palpation 
demonstrate  a  full  bladder.  On  passing  the  catheter  immediately 
after  voluntary  micturition,  residual  urine  is  drawn  and  the  ure- 
thra is  found  to  be  abnormally  long. 
To  measure  the  urethral  length,  the  Fig.  104. 

catheter  is  introduced  till  the  water 
begins  to  flow ;  its  shaft  is  then 
pinched  with  the  thumb  at  the  point 
corresponding  to  the  meatus.  The 
urethral  length  is  determined  by  with- 
drawing the  catheter  and  measuring 
the  distance  from  the  thumb  to  the 
eye  of  the  instrument.  Normally 
this  should  be  alDout  eight  inches. 

Retention  from  chronic  prostatitis  soft  rubber  catheter. 

accompanied  by  contraction  and  scle- 
rosis of  the  internal  vesical  sphincter  gives  the  same  picture,  except 
that  the  urethra  is  not  lengthened.     Rectal  palpation  shows  a  small, 
hard  prostate,  and  cystoscopic  examination  fails  to  demonstrate  nodular 
projections  at  the  vesico-urethral  junction. 

Treatme7it.— Complete  retention  from  prostatic  enlargement  always 
requires  prompt  mechanical  or  surgical  intervention.  The  time  spent 
in  palliative  measures  is  wasted,  and  may  give  an  opportunity  for  the 
development  of  irremediable  lesions.  With  very  few  exceptions,  it  is 
possible  to  pass  an  instrument  into  the  bladder.  The  surgeon  should 
be  provided  with  soft,  straight,  and  elbowed  rubber  catheters,  each 
having  a  large  sunken  eye,  a  solid  tip,  and  a  funnel  end  (Fig.  104), 
flexible  woven  olivary  (Fig.  105)  or  conical  catheters  (Fig.  106), 
woven  catheters,  single  and  double  elbowed  (Figs,  107,  108),  stiff 
English  cylindrical  catheters  (Fig.  109),  and  one  or  two  long  full- 
curved  silver  prostatic  catheters  (Fig.  110),  calibre  18  to  20  F.,  twelve 


JOS 


GENITO-UKINARY    DISEASES   AND   SYPHILIS. 


inches  in  length,  and  with  an  unusually  long  curve.  The  calibre 
of  the  soft  instruments  should  be  from  14  to  18  F.  An  irrigating 
apparatus,  provided  with  a  conical  glass  nozzle  which  can  be  fitted 
into  the  ends  of  the  catheters,  a  sterile  lubricant,  and  a  sufficient 
number  of  sterile  towels,  also  must  be  provided. 

Fig.  105. 


Olivary  catheter. 
Fig.  106. 

Conical  catheter. 
Fig.  107. 

Elbowed  catheter. 
Fig.  108. 


Double-elbowed  catheter. 
Fig.  109. 


Cylindrical  catheter. 


If  the  history  of  a  case  suggests  the  possibility  of  stricture  compli- 
cating enlarged  prostate,  the  soft,  flexible,  bulbous,  or  olivary  bougies 
will  be  required.  A  preliminary  rectal  examination  having  been 
made,  the  urethra  thoroughly  flushed  out,  and  the  penis  and  glans 


Fig.  110. 


Silver  prostatic  catheter. 


cleansed  as  for  an  operation,  a  slit  is  cut  in  a  sterile  towel,  and  through 
this  the  penis  is  slipped ;  thus  the  manipulative  area  is  surrounded 
by  a  sterile  surface.     The  surgeon,  having  sterilized  his  hands,  lubri- 


SYMPTOMATOLOGY  OF  DISEASES  OF  TJRINAEY  TEACT.        309 

cates  a  sterilized  soft  elbowed  catheter  ot  medium  size,  passes  it  to 
the  compressor  urethrae  muscle,  attaches  its  free  end  to  the  irrigator, 
and  washes  out  the  anterior  urethra ;  he  then  endeavors  to  pass 
the  instrument  into  the  bladder.  When  gently  repeated  efforts, 
continued  for  one  or  two  minutes  at  most,  fail,  the  rubber  catheter 
should  be  attached  to  the  irrigator,  and  should  be  withdrawn  while 
a  dilute  antiseptic  solution  (four  per  cent,  boric  acid)  is  flowing 
through  it.  A  woven  catheter  (coude)  is  then  tried.  The  slight 
angle  at  the  end  of  this  instrument  is  of  service,  partly  because  it 
enables  it  readily  to  override  obstacles,  and  partly  from  the  fact  that 
the  bend  keeps  the  extremity  of  the  instrument  applied  to  the  upper 
urethral  wall.  It  will  be  remembered  that  the  obstruction  is  found 
mainly  in  the  lower  and  lateral  walls  of  the  urethra,  the  upper  por- 
tion remaining  comparatively  normal.  Hence,  if  the  end  of  the  in- 
strument is  kept  constantly  in  close  contact  with  this  normal  surface, 
it'  can  be  readily  guided  into  the  bladder.  The  tip  of  the  elbowed 
catheter  must,  therefore,  be  kept  against  the  urethral  roof. 

Should  the  elbowed  catheter  fail  to  gain  an  entrance,  the  double 
elbowed  or  bi-coude  catheter  may  be  tried. 

In  the  event  of  this  failing,  a  soft  rubber  catheter  of  small  calibre. 
No.  10  to  No.  12  F.,  is  slipped  on  one  of  the  iron  wire  stylets  with 
which  English  catheters  are  provided.  The  extremity  of  this  stylet 
stops  one  inch  short  of  the  eye  of  the  catheter.  To  the  soft  rubber 
catheter,  thus  made  rigid  but  with  a  perfectly  flexible  end,  a  long  curve 
is  given  by  bending  the  wire.  This  corresponds  in  general  with  that 
of  the  prostatic  silver  catheter.  This  long  curve  keeps  the  tip  of  the 
instrument  apposed  to  the  urethral  roof  and  thus  guides  it  into  the 
bladder.  The  rigidity  imparted  by  the  stylet  enables  enough  pressure 
to  be  applied  to  overcome  any  resistance  offered  by  the  close  appo- 
sition of  tough  fibrous  walls,  and  the  flexible  end  readily  finds  its  way 
over  or  around  abrupt  projections.  All  these  manipulations  must  be 
conducted  with  the  utmost  gentleness,  yet  the  most  skilful  manipu- 
lation will  occasion  bleeding  because  of  the  intense  congestion  which 
always  accompanies  retention. 

Should  the  soft  catheter  threaded'  on  the  stylet  fail  to  pass,  the 
long  prostatic  silver  catheter  may  be  used.  In  passing  the  catheter  it 
must  be  borne  in  mind  that  the  urethra  is  always  lengthened,  some- 
times two  or  three  inches,  and  that  the  bladder  may  not  be  reached 
because  of  failure  on  the  part  of  the  surgeon  to  pass  his  instrument 
far  enough.  Sometimes  a  long  flexible  rubber  or  whalebone  guide 
can  be  made  to  pass  the  obstruction,  and  a  tunnelled  catheter  can  be 
passed  over  it,  as  in  cases  of  stricture,  although  this  procedure  is  not 


310  GENITO-UEIlSrARY   DISEASES   AND   SYPHILIS. 

SO  uniformly  useful  in  cases  of  prostatic  retention.  Should  gentle 
efforts  with  all  these  instruments,  continued  not  more  than  two  or 
three  minutes  for  each,  result  in  failure  to  reach  the  bladder,  supra- 
pubic aspiration  is  indicated. 

A  method  of  treatment  attended  with  more  mimediate  risk  than 
aspiration,  but  which  has  given  satisfactory  results  where  there  is  no 
hope  of  rehef  by  catheterization,  is  suprapubic  puncture  by  means  of 
a  curved  trocar  and  canula. 

In  cases  of  retention  from  prostatic  enlargement  uncomphcated 
by  infection,  and  particularly  when  there  have  been  no  previous  futile 
attempts  at  instrumentation,  the  soft  rubber  catheter  or  the  flexible 
woven  elbowed  catheter  usually  enters  the  bladder  without  difficulty. 
AVhen  this  end  is  accomplished  the  surgeon's  serious  responsibihty 
practically  begins.  If  as  a  result  of  long-standing  vesical  tension  there 
has  been  dilatation  of  the  ureters  or  of  the  kidney  pelves,  A^ath  marked 
alterations  in  the  kidney  structure,  and  particularly  if  there  has  been 
previous  infection,  or  if  this  is  carried  in  by  instrumentation,  sudden 
evacuation  of  urine  may  be  followed  by  suppression,  uraemia,  and 
death,  occurring  in  either  a  few  days  or  a  few  weeks.  When  the 
kidneys  are  comparatively  healthy,  sudden  complete  evacuation  of 
the  bladder-contents,  by  interfering  with  the  conditions  of  pressure 
to  which  the  blood-vessels  have  become  accustomed,  may  occasion 
severe  hemorrhage  not  only  in  the  bladder  but  in  the  kidneys  them- 
selves. This,  even  when  slight  in  degree,  by  favoring  the  develop- 
ment of  cystitis,  may  constitute  a  grave  compHcation.  If  profuse  it 
becomes  serious,  not  only  because  of  its  systemic  effect,  but  also 
because  by  clotting  and  obstructing  the  catheter  it  interferes  with  the 
flow  of  the  urine.  To  avoid  bleeding  the  urine  should  be  drawn  off 
slowly,  with  the  patient  in  a  recumbent  position.  Except  when  the 
distention  is  slight  and  of  short  duration,  the  bladder  should  never 
be  completely  emptied  at  the  time  of  the  first  catheterization.  When 
the  urine  is  clear  and  sterile,  about  half  the  bladder-contents  should 
be  ahowed  to  remain.  When  there  is  blood  or  pus  in  the  urine,  all 
of  this  should  be  drawn  from  the  bladder,  but  without  allowing  this 
viscus  to  be  entirely  empty  at  any  time.  This  end  is  attained  in  the 
following  way  :  Before  passing  the  catheter  the  bladder  is  palpated,  to 
enable  the  surgeon  roughly  to  determine  the  amount  of  tension.  The 
catheter  is  introduced  and  somewhat  more  than  half  the  retained 
urine  is  drawn.  This  may  be  two  to  three  pints.  Eight  to  twelve 
ounces  of  a  warm  sterile  four  per  cent,  solution  of  boric  acid  are  then 
injected  into  the  bladder  by  means  of  the  irrigator  and  immediately  the 
same  quantity  of  mixed  boric  acid  solution  and  urine  is  allowed  to 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINARY  TRACT.        31 1 

escape.  This  partial  filling  and  emptying  of  the  bladder  is  continued 
till  the  blood  and  pus  disappear  and  the  liquid  evacuated  has  the 
colorless  appearance  of  the  boric  acid  solution.  The  catheter  is  then 
slowly  withdrawn,  with  the  boric  acid  solution  still  flowing  through  it. 

The  immediate  dangers  of  tension  having  been  thus  removed,  the 
subsequent  treatment  of  the  bladder  must  be  clearly  formulated. 

The  invariable  rule  of  treatment  in  these  cases  should  be  regular 
evacuation  of  the  bladder,  the  number  of  catheterizations  required 
daily  being  regulated  by  the  activity  of  the  kidneys.  Four  to  eight 
times  in  twenty-four  hours  are  usually  sufficient.  Each  time  enough 
urine  is  withdrawn  to  lessen  distinctly  the  residual  amount.  This 
residuum  is  then  replaced  by  boric  acid.  By  the  end  of  a  week  the 
bladder  can  usually  be  completely  emptied  without  fear  of  ill  results. 

Even  after  the  bladder  begins  to  recover  its  tone  and  the  patient 
regains  some  power  of  passing  his  water,  he  should  be  cautioned 
against  throwing  aside  his  catheter  so  long  as  his  efforts  at  micturi- 
tion are  painful  and  are  attended  with  much  straining  and  with  a 
feeble  and  insufficient  flow  of  urine.  Continuance  of  catheterization  is 
particularly  to  be  insisted  on  when  there  is  cystitis,  since  the  abortive 
straining  efforts  at  urination  markedly  increase  local  congestion. 

If  the  urine  has  remained  sterile,  and  if  the  patient  has  regained 
the  power  of  passing  the  greater  part  of  his  water  with  comparatively 
little  effort,  it  is  then  safe  to  discard  the  catheter,  since  a  moderate 
quantity  of  sterile  residual  urine  is  hurtful  only  so  far  as  it  lessens 
bladder-capacity. 

When  the  passage  of  a  soft  instrument  is  difficult,  is  extremely 
painful,  and  is  attended  with  much  bleeding,  and  this  is  particularly 
the  case  when  there  have  been  previous  unsuccessful  attempts  at 
catheterization,  and  when  there  is  cystitis  with  purulent,  often  am- 
moniacal,  urine,  the  objects  for  which  the  instrument  is  used — i.e., 
efficient  bladder-drainage  and  relief  of  local  congestion — cannot  be 
attained,  since  frequent  passage  of  the  instrument  is  impracticable. 
Under  these  circumstances  continuous  catheterization  is  serviceable. 
When  retention  is  complicated  by  fever,  continuous  catheterization 
finds  its  most  useful  application. 

Even  in  cases  of  bleeding  from  vesical  tumor  with  infected  blad- 
der, from  the  time  of  insertion  of  the  permanent  catheter  deferves- 
cence is  rapid  and  blood  disappears,  doubtless  owing  to  the  physio- 
logical rest  given  to  the  bladder-walls.  In  the  same  way  bladder-pain 
is  relieved. 

When  in  the  course  of  intermittent  catheterization  the  introduction 
of  the  instrument  becomes  difficult,  it  is  well  to  advise  patients  to  prac- 


312  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

tise  for  some  hours  or  days  permanent  catheterization ;  the  effect  of 
the  instrument  thus  used  is  to  cause  softening  and  dilatation  of  the 
urethra,  allowing  an  easy  passage  of  the  catheter.  This  permanent 
catheter  does  not  lessen  prostatic  enlargement ;  it  simply  relieves  con- 
gestion by  providing  for  free  drainage. 

When  pain  is  caused,  this  is  due  to  improper  application  of  the 
method.  During  the  first  hours  exceptionally  there  is  a  sense  of 
weight  and  inconvenience.  This  quickly  subsides,  and  the  cath- 
eter may  then  often  be  continued  for  weeks  without  causing  any 
suffering. 

The  soft  rubber  instruments  are  best  suited  to  permanent  catheter- 
ization. If  a  woven  catheter  is  employed,  this  should  be  thin-walled, 
of  as  large  calibre  as  possible,  and  provided  with  two  large  terminal 
eyes.  They  are  placed  in  the  turned-up  portion,  and  hence  not  likely 
to  be  occluded  by  the  bladder-walls. 

Fig.  111. 


Soft  rubber  self-retaining  catheters. 

The  self-retaining  catheter  is  also  useful.  (Fig.  111.)  This  is  of 
soft  rubber,  18  to  22  F.,  and  is  provided  with  lateral  terminal  projec- 
tions, which  disappear  wiien  it  is  drawn  tightly  over  the  metal  carrier. 
It  is  thus  introduced  ;  the  carrier  is  then  withdrawn,  and  the  elasticity 
of  the  instrument  causes  the  projections  to  reappear.  The  surgeon  is 
enabled  to  determine  how  far  the  tip  of  the  instrument  is  passed  into 
the  bladder  by  gently  drawing  the  catheter  out  until  he  feels  the  resist- 
ance caused  by  these  rubber  projections  when  the  narrowing  of  the 
vesical  neck  is  reached.  When  this  resistance  is  felt,  it  is  certain 
that  the  catheter  eye  lies  just  within  the  grasp  of  the  internal  vesical 
sphincter.  If  the  elbowed  catheter  is  used,  the  exact  depth  at  which  it 
must  be  maintained  is  determined  by  gently  withdrawing  it  when  the 
contents  of  the  bladder  are  almost  evacuated  and  noting  the  moment 
when  the  stream  ceases  to  flow.  It  is  then  passed  in  again  until  the 
stream  begins  to  flow,  and  is  fixed  at  this  point. 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINARY  TRACT.        313 

To  determine  positively  that  the  instrument  is  properly  placed  and 
completely  evacuates  the  bladder,  after  the  stream  has  ceased  to 
flow  sudden  pressure  is  made  in  the  hypogastric  region.  If  the 
bladder  is  empty  there  will  be  no  jet  of  urine.  Next  a  definite  quan- 
tity of  antiseptic  solution  is  injected  into  the  bladder ;  all  of  it  should 
be  returned  immediately.  Next  the  end  of  the  catheter  should  be 
watched,  to  see  that  the  urine  drops  steadily  and  continuously. 

Fig.  112. 


Securing-  the  catheter  for  continuous  catheterization. 


When  by  all  these  tests  the  surgeon  is  sure  that  the  catheter  is 
properly  placed,  it  may  be  secured  in  position.  The  proper  placing 
of  the  instrument  is  the  most  important  part  of  the  whole  procedure. 
If  the  urine  does  not  flow  drop  by  drop,  or  if  there  are  pain  and  a 
desire  to  urinate,  this  is  usually  because  the  catheter  is  passed  too 
deeply,  and  is  corrected  by  drawing  it  out  a  little. 

The  fixation  of  the  catheter  is  accomplished  either  by  passing 


314 


GENITO-URINAR  /   DISEASES   AND   SYPHILIS. 


threads  around  it  immediately  beyond  the  urinary  meatus  and  knot- 
ting them  to  the  suprapubic  hair,  or,  better,  by  fastening  these  threads 
to  strips  of  rubber  adhesive  plaster  an  inch  wide  applied  to  either  side 
of  the  penis,  passing  from  its  root  to  the  level  of  the  meatus,  and 
secured  in  place  by  two  or  three  circular  strips,  not  passing  entirely 
around  the  penis,  and  a  narrow  gauze  bandage.  The  threads  should 
be  attached  to  the  catheter  close  to  the  meatus,  and  not  at  a  distance 
as  figured  in  the  illustration  (Fig.  112),  and  are  then  passed  through 
holes  cut  in  the  free  ends  of  the  longitudinal  plaster  strips.  (Fig.  112.) 
Or  four  threads  may  be  secured  to  the  catheter  just  beyond  the  uri- 
nary meatus,  and  these  may  be  carried  to  safety-pins  secured  in  a 
double  spica  of  the  groin.     (Fig.  113.) 

Fid.  113. 


Securing  the  catheter  for  continuous  catheterization. 

The  penis  is  then  enveloped  in  an  antiseptic  dressing.  A  square  of 
gauze  made  of  ten  or  twelve  layers  is  folded  in  the  form  of  a  triangle  ; 
the  apex  is  secured  to  the  catheter  just  beyond  the  meatus  by  a  silk 
thread  and  rubber  bandage ;  the  base  is  wrapped  around  the  penis. 
By  means  of  a  piece  of  sterile  glass  tubing  a  clean  rubber  drainage- 
tube  is  attached  to  the  end  of  the  catheter,  and  is  passed  into  a 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINAEY  TRACT.        31 5 

urinal  which  is  half  filled  with  antiseptic  solution  and  placed  at  a 
level  lower  than  that  of  the  bladder.  The  flow  must  be  con- 
tinuous. 

The  catheter  is  changed  every  one  or  two  days,  the  anterior 
urethra  receiving  a  thorough  irrigation  at  the  time  of  changing.  The 
catheter  is  left  open  when  it  is  employed  for  the  purpose  of  a  drain, — 
that  is,  when  it  is  used  to  combat  infection.  When  the  bladder  is 
aseptic  and  the  urine  sterile,  the  catheter  is  opened  only  at  regular 
intervals,  depending  upon  the  amount  of  urine  secreted.  This  form 
of  intermittent  drainage  is  absolutely  indicated  when  long-standing 
retention  is  being  treated.  If  the  urine  contains  pus  or  blood,  the 
residuum  which  it  is  considered  desirable  to  leave  in  the  bladder  is 
replaced  by  boric  acid  solution.  The  bladder  is  not  entirely  emptied 
for  several  days. 

Continuous  catheterization  occasions  a  mechanical  urethritis, 
which  promptly  disappears  when  the  catheter  is  removed.  Some- 
times abscesses  develop,  particularly  at  the  scrotal  angle  of  the  penis, 
due  to  pressure  exercised  by  the  instrument  on  account  of  the  penis 
being  allowed  to  hang  directly  downward.  Infection  of  the  bladder 
may  occur  either  from  direct  extension  of  urethral  inflammation  or  as 
a  result  of  the  decomposition  of  the  urine  with  which  the  interior  of 
the  catheter  is  continually  moist.  This  accident  may  be  avoided  by 
changing  the  catheter  before  its  surface  becomes  roughened,  keeping 
its  end  beneath  the  surface  of  a  strong  antiseptic  solution  contained  in 
a  clean  urinal,  and  twice  daily  flushing  the  urethra  with  hot  sterile 
four  per  cent,  boric  solution  or  protargol  solution  1  to  4000.  This 
flushing  may  be  accomplished  by  means  of  an  irrigating-bag  hung  four 
feet  above  the  level  of  the  patient's  bladder.  The  nozzle  of  the  bag  is 
.attached  to  the  catheter,  and  the  latter  is  slowly  withdrawn  till  the 
antiseptic  solution  escapes  from  the  meatus.  From  half  a  pint  to  a 
pint  of  the  solution  is  used  to  wash  out  the  anterior  urethra ;  the  irri- 
gating-bag is  then  disconnected,  and  the  catheter  is  pushed  in  till  it 
occupies  its  proper  position.  Ulceration  of  the  urethral  floor  may  be 
avoided  by  supporting  the  penis  so  that  it  is  prevented  from  hanging 
with  too  pronounced  a  curve. 

Continuous  catheterization  having  been  kept  up  for  eight  to  sixteen 
days,  and  fever,  pain,  blood,  and  the  greater  part  of  the  pus  having 
disappeared,  the  patient  can  resort  to  intermittent  catheterization. 
Exceptionally  the  bladder  can  be  emptied  by  muscular  effort,  the 
cure  being  complete.  This  result,  however,  cannot  be  looked  for  in 
retention  caused  by  prostatic  overgrowth. 

Patients  whose  symptoms  have  been  relieved  by  continuous  cathe- 


316  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

terization  should  be  told  to  resort  again  to  this  measure  should  they 
experience  difficulty  in  passing  the  instrument.  The  catheter  may 
be  worn  at  night  or  for  several  hours  at  a  time  during  the  day. 

The  indications  for  continuous  catheterization  and  the  methods  of 
employing  it  in  the  treatment  of  retention  may  be  summarized  as 
follows : 

1.  Continuous  catheterization  is  indicated  in  retention  following^ 
wounds  or  rupture  of  the  urethra.  It  is  particularly  indicated  when 
prostatic  retention  is  not  amenable  to  repeated  catheterization  and  is 
complicated  by  bleeding  or  by  infection  and  fever. 

2.  The  catheter  chosen  must  be  large,  thin-walled,  and  carefully 
made  ;  the  catheter  eye  must  lie  just  within  the  internal  vesical  sphinc- 
ter, and  must  be  kept  open.  The  instrument  should  be  changed 
every  second  day.  Its  free  end  should  be  kept  beneath  the  surface 
of  an  antiseptic  lotion  held  in  a  urinal  so  placed  as  to  be  beneath  the 
level  of  the  bladder.  The  urethra  should  be  flushed  out  twice  daily 
with  a  pint  of  dilute  antiseptic  solution.  When  the  urine  is  sterile,  the 
bladder  need  not  be  washed  ;  when  it  contains  pus  or  blood,  it  should 
be  irrigated  at  least  twice  daily.  The  catheter  should  drain  the 
bladder  continuously  when  it  is  employed  for  the  relief  of  partial  re- 
tention without  marked  vesical  tension  complicated  by  cystitis  and 
fever.  It  should  drain  the  bladder  intermittently  when  the  urine  is 
sterile  and  when  it  has  been  introduced  for  the  relief  of  retention 
with  marked  vesical  tension. 

Continuous  catheterization  reheves  tension,  cures  cystitis,  makes 
the  passage  of  instruments  easier,  and  in  general  value  and  varied 
applicabihty  is  second  only  to  intermittent  catheterization. 

Aspiration. — When  catheterization  fails  to  relieve  retention  from 
an  enlarged  prostate,  aspiration  is  the  operation  of  choice.  This  is 
safe  and  easy,  and  can  be  repeated  very  often  without  causing  com- 
plications of  any  kind. 

The  bladder  is  outlined  by  percussion  and  palpation,  the  supra- 
pubic region  is  thoroughly  cleansed  as  for  a  formal  surgical  operation^ 
the  large  aspirating  needle  is  boiled,  and  the  surgeon's  hands  are  steril- 
ized. With  a  sterile  sharp-pointed  tenotome  a  puncture  is  made 
through  the  skin  of  the  middle  line  immediately  above  the  symphysis 
pubis,  and  the  aspirating  needle  is  thrust  downward  and  backward 
through  this  incision  into  the  bladder.  The  lessened  resistance  will 
determine  when  it  has  penetrated  through  all  the  walls  of  this 
viscus. 

The  bladder  is  partially  or  completely  emptied,  in  accordance 
with  the  duration  of  retention  and  the  amount  of  vesical  distention. 


SYMPTOMATOLOGY  OF  DISEASES  OF  TJEINARY  TRACT.        317 

The  aspirating  needle  is  then  withdrawn,  while  suction  is  still  main- 
tained, thus  preventing  infection  of  the  needle-track  with  the  urine. 

These  aspirations  may  be  repeated  three  or  four  times  a  day  for 
one  or  two  weeks  without  infecting  the  bladder,  and  usually  Avithout 
causing  suppuration  of  the  prevesical  cellular  tissues.  It  is  worthy 
of  note,  however,  that  a  few  cases  of  extra-vesical  abscess  have  been 
reported,  but  only  when  there  has  been  pronounced  cystitis. 

Incomplete  Retention. — The  damage  inflicted  by  incomplete 
retention  upon  the  bladder,  ureters,  and  kidneys  is  commonly  more 
pronounced  and  more  permanent  in  its  effects  than  that  incident  to 
complete  retention,  since  in  the  latter  case  the  symptoms  are  so  urgent 
that  prompt  relief  by  catheterization  is  obtained,  whilst  in  the  former, 
the  symptoms  being  annoying  rather  than  painful,  there  is  a  pro- 
gressive, often  rapid,  dilatation  of  the  bladder  followed  by  all  the  evil 
effects  of  back  pressure. 

Patients  suffering  from  incomplete  retention  due  to  prostatic  en- 
largement may  complain  of  no  symptoms  other  than  undue  frequency, 
slowness  in  starting  the  stream,  and  lack  of  propulsive  force.  Cystitis 
or  acute  prostatic  congestion  aggravates  these  symptoms  and  sup- 
plements them  by  pain  and  tenesmus.  In  the  early  stages  of  incom- 
plete chronic  congestion  before  the  bladder  is  markedly  dilated,  as 
determined  by  rectal  and  suprapubic  palpation  and  measurement  of 
the  residual  urine,  the  treatment  of  these  occasional  exacerbations 
calls  for  active  purgation,  hot  normal  saline  enemata,  hot  Sitz  baths, 
diluents  by  the  mouth,  a  bland  diet,  and  rest  in  bed.  In  the  aJasence 
of  vesical  infection,  the  catheter  may  be  omitted  unless  there  is  over- 
distention,  when  instrumental  relief  is  imperatively  called  for. 

Treatment  of  Chronic  Incomplete  Retention. — After  the  surgeon 
has  relieved  the  acute  retention  of  prostatics,  has  checked  bleeding, 
and  has  cured  or  alleviated  the  chronic  cystitis  from  which  these 
patients  usually  suffer,  directions  must  be  given  which  will  prevent  a 
return  of  complete  retention  and  which  will  keep  the  bladder  in  the 
best  condition  to  resist  microbic  invasion  and  preserve  it  from  the 
effects  of  abnormal  tension.  This  necessarily  implies  the  habitual  or 
intermittent  use  of  a  catheter.  Perhaps  a  point  of  prime  importance 
is  to  convince  these  patients  that  the  catheter  does  not  cause  vesical 
atony  and  cystitis,  but  protects  against  these  sequelae  of  prostatic  en- 
largement ;  that  its  use  does  not  abolish  the  power  of  urination,  but 
may  restore  it ;  and  that  it  is  infinitely  better  to  draw  the  water 
through  an  instrument  than  to  pass  it  at  the  expense  of  prolonged  and 
violent  straining  efforts. 

Instruction  must  next  be  given  in  the  technique  of  catheterization. 


318  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

The  mere  mechanical  part  is  learned  quicicly  enough.  The  instrument 
which  in  each  case  enters  the  bladder  most  readily  and  gives  least 
pain  is  the  best.  This  may  be  a  soft  rubber  catheter,  an  elbowed  or 
double-elbowed  catheter,  the  stiff  English  instrument,  or  exceptionally 
even  the  silver  prostatic  catheter. 

The  number  of  catheterizations  a  day  must  be  regulated  by  the 
activity  of  the  kidneys  and  by  the  frequency  with  which  the  patient  ex- 
periences a  strong  persistent  desire  to  urinate.  In  mild  cases  suffer- 
ing only  from  frequent  urination  at  night  the  passage  of  an  instrument 
before  retiring  is  usually  sufficient.  During  the  day  there  are  no  dis- 
tress, but  little  delay  or  straining,  a  free  flow  of  urine,  and  no  disturb- 
ing frequency.  In  more  advanced  cases  where  the  urine  is  still  passed 
freely  and"  painlessly,  but  there  is  a  large  residuum  with  troublesome 
frequency,  the  catheter  may  have  to  be  passed  two  or  three  times  in 
the  day.  Where  there  is  chronic  cystitis  or  congestion  with  frequent, 
urgent,  painful,  and  inefficient  urination,  the  catheter  may  have  to  be 
used  every  two  or  three  hours  ;  when  the  urine  is  purulent  its  evacu- 
ation should  always  be  followed  by  vesical  and  urethral  irrigation. 
When  catheterization  becomes  painful  and  fails  to  give  relief,  continu- 
ous catheterization  should  be  practised  for  a  few  days. 

Minute  directions  should  be  given  patients  concerning  the  care  of 
instruments  and  a  cleanly  method  of  using  them.  They  must  be 
taught  the  importance  of  using  sterile  catheters  in  accordance  with 
modern  surgical  principles.  This  is  especially  necessary  when  cys- 
titis has  not  developed.  The  various  ingenious  contrivances  in  which 
patients  carry  their  instruments — for  instance,  flat  boxes  and  hollow 
canes — are  not  to  be  commiended,  since  it  is  almost  impossible  to 
keep  catheters  clean  when  they  are  thus  stored.  Catheterization  is 
troublesom.e  at  best,  and  thoroughness  in  carrying  out  antiseptic  de- 
tails should  not  be  sacrificed  to  convenience. 

The  most  comfortable  catheter  having  been  selected,  the  patient 
should  procure  twice  as  many  of  these  as  are  required  in  a  single  day, 
a  fresh  instrument  being  used  for  each  catheterization.  In  the  selec- 
tion of  these  instruments  it  is  worthy  of  note  that  those  of  American 
make  are  quite  as  good  as  the  imported  ones,  and  that  the  Lisle  thread 
and  linen  catheters  are  practically  as  serviceable  as  those  of  pure 
silk.  In  addition  to  the  catheters  the  patient  must  secure  a  metal  box 
arranged  for  their  sterilization  by  paraform,  tubes  of  carbolized  cos- 
moline,  or  other  slightly  antiseptic  lubricant,  a  bottle  of  tablets  of 
corrosive  mercuric  chloride  for  making  a  solution  of  1  to  1000  in 
which  the  hands  can  be  washed,  a  roll  of  bichloride  gauze,  and  an 
irrigating-bag.     He  should  have  prepared  a  dozen  clean  towels  which 


SYMPTOMATOLOGY  OF  DISEASES  OF  UPJNAEY  TKACT.        319 

have  been  boiled  and  sun-dried  or  baked.  The  catheters  are  washed 
in  green  soap  and  hot  boiled  water,  washed  again  in  hot  water,  dried 
with  a  clean  towel,  and  wrapped  each  in  a  piece  of  bichloride  gauze 
cut  to  an  appropriate  size.  They  are  then  loosely  wrapped  in  a  towel 
and  placed  for  ten  minutes  in  an  oven  kept  at  about  160°  F.  They 
are  finally  stored  in  the  metal  paraform-box  for  twenty-four  hours. 
(See  page  282.) 

As  each  catheter  is  required  for  use  it  is  taken  from  the  dox,  and, 
with  its  gauze  wrapping  still  unfolded,  is  placed  on  a  clean  towel.  The 
patient  then  fills  his  irrigating-bag  with  a  solution  of  1  to  2000  pro- 
targol,  removes  the  cap  from  the  lubricant  jar,  scrubs  his  hands  thor- 
oughly with  soap  and  hot  water,  washes  them  in  bichloride  solution 
— 1  to  1000 — scrubs  the  glans  penis  with  a  pledget  of  cotton  dipped  in 
this  same  solution,  again  washes  his  hands  in  the  bichloride  solution, 
unwraps  the  catheter,  dips  it  for  a  moment  in  a  pitcher  of  hot,  re- 
cently boiled  water,  hot  boric  acid  solution,  or  1  to  10,000  corrosive 
chloride  solution,  to  remove  the  paraform  vapor,  lubricates  it  carefully, 
places  a  clean  towel  around  the  penis,  and  introduces  the  instrument, 
attaching  the  irrigating  apparatus  after  it  has  been  passed  in  four 
inches  and  allowing  the  antiseptic  solution  to  flow  while  the  catheter 
is  slowly  pushed  on  into  the  bladder.  After  the  bladder  is  emptied, 
the  irrigator  is  again  attached  to  the  catheter  during  its  withdrawal. 
The  catheter  thus  used  is  immediately  washed  and  syringed  out  with 
hot  soapsuds,  is  dipped  for  a  moment  in  boiling  water,  is  then  shaken 
to  dry  out  its  interior  as  thoroughly  as  possible,  is  wiped  dry,  and  is 
wrapped  in  a  clean  towel.  At  night  the  hands  are  cleansed,  and  the 
catheters  which  have  been  used  during  the  day  are  again  wrapped  in 
bichloride  gauze,  baked  for  a  few  minutes,  and  put  in  the  paraform- 
box.  This  box  should  be  provided  with  two  shelves,  each  containing 
enough  catheters  for  twenty-four  hours'  use. 

The  baking  is  not  absolutely  essential,  since  its  main  purpose  is  to  dry 
the  interior  of  the  instruments  and  thus  prevent  them  from  deteriorating. 

There  are  many  simpler  methods  of  practising  cleanliness  in  cathe- 
terization.    We  believe  the  method  given  above  is  the  most  efficient. 

When  it  cannot  be  carried  out,  the  catheters  should  be  boiled 
and  wrapped  in  sterile  towels.  The  hands  and  the  glans  penis  should 
be  washed  with  bichloride  and  the  urethra  should  be  cleansed  by 
antiseptic  injections  practised  with  an  ordinary  urethral  syringe  before 
each  passage  of  the  instrument.  As  the  latter  is  withdrawn,  the 
urethra  should  again  be  flushed  with  the  antiseptic. 

When  about  to  travel,  enough  catheters  should  be  sterilized  to  last 
at  least  two  days.     These,  with  the  catheter  case,  lubricant,  antiseptic 


320  GENITO-UEINAEY   DISEASES   AiS^D   SYPHILIS. 

towels,  gauze,  absorbent  cotton,  a  small  basin  for  hand  solution,  and  a 
narrow  pint  jar  for  rinsing  the  formalized  catheter  may  be  packed  in  a 
small  valise. 

When  the  above  technique  is  rigidly  enforced,  the  severe  grades  of 
traumatic  urethritis  incident  to  repeated  and  frequent  unclean  cathe- 
terization may  be  avoided. 

When  cystitis  is  present  irrigations  are  extremely  valuable.  A 
fountain  syringe  is  used,  and  in  general  a  solution  is  employed  which 
does  not  excite  inflammatory  reaction.  Even  when  the  urine  remains 
sterile,  should  frequent  catheterization  occasion  a  simple  urethritis, 
the  anterior  urethra  should  always  be  irrigated  just  before  the  instru- 
ment is  passed  into  the  bladder  and  during  its  withdrawal. 

A  patient  suffering  from  enlarged  prostate  should  also  be  given 
careful  instructions  in  regard  to  the  prophj^axis  of  the  congestive 
attacks  which  so  frequently  cause  acute  retention. 

The  diet  must  be  so  regulated  that  the  urine  shall  be  unirritating. 
This  necessarily  implies  treatment  for  oxaluria,  excess  of  uric  acid,  or 
other  abnormal  condition.  Diluents  should  be  given  with  the  same 
end  in  view,  but  not  to  the  extent  of  markedly  increasing  the  polyuria 
which  is  usually  present.  The  surface  circulation  should  be  stimu- 
lated by  bathing,  friction,  and  massage.  Open-air  exercise  is  desirable 
for  its  effect  upon  the  general  health.  Even  horseback  riding  or  the 
use  of  a  bicycle  is  sometimes  followed  by  beneficial  results.  Tonics, 
stimulants,  and  nutrients  all  have  their  value. 

As  a  means  of  avoiding  local  congestions  the  patients  must  be 
particularly  cautioned  against  constipation,  chilling  of  the  surface,  wet 
feet,  resisting  the  desire  to  urinate,  sexual  excess,  indulgence  in  alco- 
hol, or  overeating.  The  treatment  directed  to  lessening  the  hyper- 
trophy is  discussed  under  a  separate  heading. 

RETENTION  OF  URINE  FROM  STRICTURE. 
The  retention  of  urine  from  stricture  must  be  distinguished  from 
that  dependent  upon  enlarged  prostate,  since  the  treatment  of  the 
two  affections  is  widely  different.  In  both  cases  there  is  usually  a 
preceding  history  of  frequent  urination  with  slowness  in  starting  the 
stream.  Prostatics,  however,  have  most  difficulty  at  night  and  in  the 
early  morning.  During  the  day  the  water  flows  with  comparative 
freedom  .and  without  much  delay.  Examination  per  rectum  will 
usually  show  enlargement  of  the  prostate.  In  cases  of  stricture  the 
frequency  is  most  pronounced  in  the  day,  the  delay  in  starting  the 
stream  is  less  marked,  and  there  is  liable  to  be  more  dribbhng.  Until 
retention  is  well  advanced  there  is  distinct  remission  of  symptoms  at 


SYMPTOMATOLOGY  OF  DISEASES  OF  UEINARY  TRACT.        321 

night.  A  history  of  previous  gleet  or  of  injury  to  the  perineal  or  the 
penile  urethra  is  usually  given.  It  must  be  recognized  that  sudden 
retention  may  develop  in  cases  of  stricture  of  large  calibre  w^ithout 
a  preceding  history  of  frequency. 

The  diagnosis  is  generally  founded  upon  exploration  of  the 
urethra  with  acorn- bougies  and  digital  examination  through  the 
rectum. 

There  is  probably  incomplete  retention  in  the  majority  of  tight 
strictures,  but  of  a  degree  insufficient  to  produce  dangerous  vesical 
tension.  Any  cause  of  congestion  and  urethral  spasm,  particularly 
sexual  indulgence,  excess  in  drink,  chiHing  of  the  surface,  or  the  pas- 
sage of  a  catheter,  may  make  the  retention  complete.  This  form  of 
complete  retention  is,  however,  of  short  duration. 

Treatment. — Since  the  bladder  has  a  tendency  to  become  hyper- 
trophied  rather  than  dilated,  it  is  rare  in  the  case  of  stricture  to  find 
it  enormously  distended.  Even  when  the  tension  is  still  moderate, 
the  suffering  is  so  intolerable  that  the  help  of  the  surgeon  is  de- 
manded. Since  spasm  and  congestion  play  the  major  role,  a  hot 
bath,  hot  enemata,  opium  and  belladonna  suppositories,  and  hot  tur- 
pentine stupes  over  the  hypogastrium  may  be  tried.  If  these  meas- 
ures fail,  the  surgeon  should  promptly  proceed  to  instrumentation. 
On  the  chance  of  the  stricture  being  of  large  calibre  and  of  the  reten- 
tion being  caused  mainly  by  muscular  spasm,  an  effort  may  be  made 
to  introduce  a  steel  sound,  16  to  20  F.,  into  the  bladder.  If  this  fails, 
fine  conical  and  rat-tailed  soft  catheters  should  next  be  tried.  These 
failing,  fiUform  whalebone  bougies  should  be  used,  and  gently  manipu- 
lated till  one  enters  the  bladder.  When  the  fihform  has  entered  the 
distended  bladder,  it  may  be  tied  in  place,  with  the  full  assurance  that 
enough  urine  will  leak  out  beside  it  to  relieve  tension,  and  that  the 
stricture  will  be  sufficiently  softened  to  allow  of  the  passage  of  larger 
instruments. 

This  is  the  simplest  course,  and  probably  the  safest  in  the  majority 
of  cases,  especially  when  patients  are  treated  at  their  own  homes. 
When  they  are  under  hospital  supervision,  however,  good  results  will 
be  obtained,  and  more  expeditiously,  by  cutting  the  stricture  to  full 
calibre  at  once  either  by  internal  or  external  urethrotomy  or  by  a 
combination  of  these  methods. 

When  a  filiform  cannot  be  passed,  aspiration,  by  relieving  tension 
and  congestion  and  relaxing  spasm,  will  at  times  be  followed  by  suc- 
cess on  subsequent  efforts  to  pass  instruments  through  the  urethra. 
Usually  on  failure  to  pass  any  instrument  external  urethrotomy  is 
rec[uired. 

21 


322 


rjBNiTO-UEINARY   DISEASES   AND   SYPHILIS. 


PRETENTION  OF  Urine  FROM  TRAUMATISM. — Under  tliis  heading  is 
included  that  form  of  retention  which  follows  direct  injury  of  the 
urethra  or  the  bladder.  Retention  following  general  trauma,  such 
as  that  observed  in  the  aged  after  contusion  of  the  hip  or  frac- 
ture of  the  thigh,  is  probably  due  to  disordered  reflexes  (inhibi- 
tion of  the  detrusors  or  spasm  of  the  sphincters),  and  is  elsewhere 
described. 

Rupture  of  the  bladder  may  cause  retention,  partly  because  the 
urine  escapes  through  the  rent,  partly  from  muscular  palsy.  Lacera- 
tion or  rupture  of  the  urethra  always  causes  retention.  The  symp- 
toms and  treatment  of  these  injuries  have  been  considered  under 
separate  headings.  The  general  indications  are  immediate  closure 
of  the  rupture  and  drainage  of  the  bladder  either  by  continuous 
catheterization  or  by  the  perineal  drainage-tube. 


INCONTINENCE  OF  URINE. 
Incontinence  of  urine  results  from  inability  of  the  bladder  to  act 
as  a  reservoir,  and  is  characterized  by  the  involuntary,  sometimes 
the  unconscious,  escape  of  urine.  Guyon  distinguishes  as  true  incon- 
tinence that  in  which  the  urine  escapes  without  previous  urgency 
or  even  desire,  thus  excluding,  for  instance,  those  cases  of  prostato- 
cystitis  in  which  the  desire  is  so  imperious  and  irresistible  that  the 
patient  cannot  withstand  it.     He  thus  tabulates  true  incontinence : 


Inconti- 
nence. 


(•  Without  material 
lesions  of  the 
urinary  tract. 


With  material  le- 
sions of  the  uri- 
nary tract. 


Without  retention 
of  urine. 


With  retention  of 
urine. 


Incontinence  from  nerve-lesions. 
Incontinence  from  nervous  affections. 
Incontinence  of  children. 

Mechanical  incontinence. 

Incontinence  of  tuberculosis. 

Traumatic  incontinence. 

Incontinence  from  urethral 
insufficiency. 

Incontinence  of  stricture. 

Incontinence     of     enlarged 
prostate. 


I 


Incontinence  without  Lesions  of  the  Urinary  Tract. — In- 
continence due  to  nerve  lesion  is  usually  preceded  by  retention,  the 
urine  escaping  drop  by  drop  from  the  overfull  bladder.  The  con- 
ditions, such  as  the  palsies  and  degenerations,  which  occasion  this 
retention  have  been  already  mentioned.  The  appropriate  treatment 
is  regular  aseptic  evacuation  of  the  bladder. 

Incontinence  of  nervous  affections  often  appears  in  the  form  of  an 
unconscious  escape  of  urine  from  the  bladder,  which  is  never  over- 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINARY  TRACT.        323 

distended.  Hysteria,  neurasthenia,  incipient  diabetes,  and  epilepsy 
occasion  this  form  of  incontinence. 

Epileptic  incontinence  is  of  special  interest,  since  it  may  be  the 
only  symptom  to  excite  suspicion  of  the  nervous  affection.  Trousseau 
states  that  adults  who,  without  lesion  of  the  urethra  or  bladder, 
wet  their  beds  at  night  should  be  suspected  of  epilepsy.  In  these 
cases  suspicion  as  to  epilepsy  having  been  excited  will  lead  to  the 
detection  of  other  symptoms,  which  may  justify  a  positive  diagnosis. 
In  hysteria  and  neurasthenia  the  condition  is  rare.  Any  violent 
emotion,  particularly  fright,  may  occasion  this  form  of  incontinence. 

Incontinence  of  children  is  essentially  a  functional  disease.  It 
usually  begins  about  the  fourth  or  fifth  year,  but  sometimes  is  con- 
tinued from  early  infancy.  There  is  a  natural  tendency  towards  cure 
at  the  period  of  puberty,  but  many  cases  persist  beyond  this  time. 
It  is  almost  invariably  nocturnal.  Exceptionally  it  is  both  nocturnal 
and  diurnal.  The  cause  of  this  incontinence  is  unknown.  Heredity 
is  a  distinctly  predisposing  factor.  The  possibility  of  epilepsy  as  an 
etiological  factor  should  always  be  carefully  considered. 

Trousseau  classifies  this  affection  as  a  neurosis,  characterized  by 
excessive  irritability  and  exaggerated  tonicity  of  the  vesical  muscles. 
Perhaps  the  most  satisfactory  explanation  is  that  which  attributes 
this  perversion  of  function  to  an  increased  irritability  of  the  pros- 
tatic urethra.  It  has  been  already  shown  that  as  the  bladder  be- 
comes distended  the  internal  vesical  sphincter  yields,  and  the  pror.- 
tatic  urethra  forms  a  portion  of  the  urine-containing  cavity.  With 
the  yielding  of  the  vesical  sphincter  and  the  penetration  of  the  urine 
into  the  prostatic  urethra  normally  there  may  be  felt  merely  a  slight 
desire  to  urinate.  It  is  only  when  the  vesical  tension  reaches  a 
certain  point  that  the  desire  to  micturate  is  felt  strongly.  In  cases 
of  posterior  urethritis,  because  of  the  increased  sensibility  of  the  pros- 
tatic urethra,  the  moment  the  internal  vesical  sphincter  yields  and 
allows  the  urine  to  reach  this  inflamed  mucous  membrane,  the  desire 
to  urinate  is  urgent,  imperative,  and  often  irresistible.  In  the  case  of 
a  child  with  a  hyperaesthetic  posterior  urethra,  and  with  spinal  re- 
flexes much  more  readily  excited  than  in  adults,  particularly  during 
sleep,  the  escape  of  the  first  few  drops  of  urine  into  the  prostatic 
urethra  is  probably  sufficient  to  set  in  active  operation  the  nervous 
and  muscular  mechanism  of  micturition.  During  the  day  cerebral 
control  is  usually  able  to  inhibit  this  reflex ;  but  when  the  prostatic 
urethra  is  particularly  irritable  the  reflex  is  excited  so  suddenly 
that  urination  takes  place  before  the  child  has  time  to  control  it  by  a 
conscious  effort. 


324  GElSriTO-URINARY   DISEASES   AND   SYPHILIS. 

Diagnosis. — Before  deciding  that  a  child  who  wets  his  bed  at 
night  or  soils  his  clothing  in  the  daytime  is  suffering  from  a  purely 
functional  trouble,  diabetes,  polyuria,  vesical  tuberculosis,  cystitis, 
nephritis,  calculus,  and  foreign  body  must  be  eliminated.  If  the 
urine  is  perfectly  normal,  and  is  not  excessive  in  cfuantity,  and  if  urina- 
tion is  painless  and  is  normally  accomplished,  these  various  causes 
of  incontinence  can  be  eliminated.  Epilepsy  must  be  excluded  by 
having  the  child  watched  through  several  nights. 

Treatment. — Since  incontinence  in  children  is  often  due  to  an  ex- 
aggerated reflex,  a  careful  search  must  be  made  for  any  abnormality 
which  may  indirectly  lead  to  such  increased  reflex  excitability. 
Thus,  the  anus  and  the  rectum  should  be  examined  for  polyp,  eczema, 
fissure,  or  seat-worms.  The  urethra  should  be  explored  for  narrow- 
ings  or  valvular  formations,  and,  since  most  children  are  phimotic,  it 
is  well  on  general  principles  to  practise  circumcision.  This  in  itself 
is  often  curative.  Errors  of  diet  must  be  carefully  corrected,  and  the 
urine  rendered  bland  by  giving  water  and  milk  in  abundance.  Liquids 
should  not,  however,  be  given  in  the  evening.  The  total  quantity  of 
urine  passed  in  twenty-four  hours  should  be  measured.  This  may 
sh(J!wthat  the  incontinence  is  really  due  to  over-distention,  the  patient 
secreting  during  the  night  more  urine  than  the  bladder  can  retain. 

The  general  system  should  be  strengthened  by  exercise  in  the 
open  air,  regular  bathing,  massage  in  the  case  of  very  weak  children, 
and  the  administration  of  tonics.  Compound  syrup  of  the  hypo- 
phosphites  in  doses  suited  to  the  age  is  particularly  serviceable.  It  is 
well  to  encourage  the  child  in  the  habit  of  defecating  immediately 
before  bedtime.  This  end  may  be  accomplished  by  the  regular  use 
of  enemata.  If  the  examination  of  the  urine  shows  oxalates  or 
other  sediments  in  excess,  the  appropriate  dietetic  regulations  should 
be  enforced. 

It  sometimes  happens  that  a  habit  of  nocturnal  incontinence  is 
due  originally  to  carelessness.  The  child,  though  awakened  by  the 
desire  to  urinate,  prefers  wetting  his  bed  to  getting  up.  Shortly  he 
is  so  imperfectly  awakened  that,  though  micturition  is  partially 
volitional,  he  is  practically  unconscious  of  the  act.  It  will  be  found 
that  the  urine  is  passed  at  about  the  same  hour  every  night.  If  the 
nurse  is  directed  to  inspect  the  child  hourly  for  two  or  three  nights, 
the  time  of  semi-conscious  urination  may  be  determined. 

In  these  cases  a  cure  may  be  accomplished  by  having  the  child 
waked  at  about  one  or  two  in  the  morning,  or  an  hour  before  his 
habitual  time  of  involuntary  micturition,  and  made  to  empty  his 
bladder.     This  treatment  may  be  reinforced  by  a  system  of  rewards 


SYMPTOMATOLOGY  OF  DISEASES  OF  UEINAEY  TKACT.       325 

and  punishment.  The  child  should  never  be  severely  disciplined, 
since  perhaps  in  the  majority  of  cases  the  disturbance  of  function  is 
entirely  beyond  his  control. 

As  further  means  of  lessening  the  tendency  to  nocturnal  enuresis, 
the  application  of  a  bandage  about  the  waist  of  the  child,  with  a  pro- 
jection in  the  back  so  that  he  is  compelled  to  Me  on  his  side,  sleeping 
on  a  comparatively  hard  bed  with  covering  just  sufficient  for  neces- 
sary warmth,  the  elevation  of  the  foot  of  the  bed,  and  counter-irrita- 
tion in  the  form  of  blisters  over  the  lumbar  spine,  have  been  tried 
with  apparently  satisfactory  results. 

Medicinal  Treatment. — The  drugs  administered  for  the  cure  of 
enuresis  in  children  are  belladonna,  atropine,  hyoscine  or  hyoscya- 
mine,  potassium  bromide,  and  quinine. 

Belladonna,  the  drug  upon  which  reliance  has  been  chiefly  placed, 
is  administered  in  ascending  doses  until  either  the  physiological  effect 
is  obtained  or  the  incontinence  is  cured.  This  drug  is  pushed  to  the 
limit  of  safety ;  thus,  a  child  four  years  old  may  be  given  an  eighth 
of  a  grain  of  belladonna  extract,  four  drops  of  the  tincture,  or  one  to 
two  minims  of  the  fluid  extract  of  the  root  in  the  evening.  Or  the 
drug  may  be  given  in  the  form  of  suppository,  the  dose  then  being 
slightly  larger.  Hyoscine  or  hyoscyamine  may  be  employed  in  doses 
of  the  two-hundred-and-fiftieth  of  a  grain  ;  potassium  bromide,  five  to 
fifteen  grains  ;  quinine,  two  to  ten  grains. 

If  the  desired  result  is  not  quickly  accomplished,  no  benefit  is 
obtained  by  continuing  these  drugs.  Sometimes  the  enuresis  is 
apparently  cured  at  once.  Under  these  circumstances  the  dose 
should  be  gradually  lessened.  If  there  is  temporary  relief  followed 
by  relapse,  the  dose  may  be  cautiously  increased.  Quinine  has  been 
particularly  commended  by  Potts,  on  the  theory  that  enuresis  is 
probably  caused  in  the  greater  number  of  cases  by  failure  of  the 
higher  centres  to  control  properly  the  reflex  act  by  which  the  blad- 
der is  emptied.  Quinine  was  given  in  full  doses  as  a  stimulant  to  the 
inhibitory  centre,  with  strikingly  satisfactory  results  in  the  few  cases 
in  which  it  was  tried. 

Mechanical  Treatment. — When  the  methods  already  discussed  have 
failed,  the  prostate  and  the  urethra  should  receive  direct  mechanical 
treatment.  This  may  be  applied  in  the  form  of  (1)  sounds,  (2)  elec- 
tricity, (3)  instillations,  (4)  epidural  or  presacral  injections. 

Its  object  is  to  relieve  the  hypersesthesia  and  congestion  of  the 
prostatic  urethra  and  to  stimulate  the  sphincter  muscle. 

The  passage  of  a  cold  steel  sound  of  such  size  that  it  enters  the 
bladder  without  the  employment  of  force  is  usually  efficacious.     This 


326  GENITO-UKIXAKY    DISEASES   AND   SYPHILIS. 

sound  should  be  left  in  place  for  from  three  to  five  minutes,  and 
should  be  passed  every  third  or  fourth  day. 

If  after  three  weeks  of  sounding  and  a  fourth  week  of  rest  symp- 
toms are  not  improved,  electricity  should  be  employed.  This  is  ap- 
plied by  means  of  a  urethral  electrode  vulcanized  to  within  an  inch 
of  its  extremity,  shaped  like  a  sound,  and  with  the  rather  sharp  curve 
appropriate  to  the  urethra  of  children.  The  electrode  is  passed  into 
the  urethra  until  its  metal  extremity  lies  within  the  membranous  and 
prostatic  portions  of  this  canal.  It  is  then  attached  to  the  far'adic 
battery,  the  other  electrode  of  which  is  applied  over  the  perineum  or 
to  the  lumbar  spine.  The  patient  is  given  fifty  slow  interruptions, 
the  current  being  so  regulated  that  it  does  not  cause  pain.  The  treat- 
ment is  repeated  every  three  or  four  days.  The  rectal  electrode  is 
less  pamful  and  nearly  as  efficacious. 

If  in  three  or  four  weeks  electrical  treatment  does  not  improve  or 
cure  the  enuresis,  instillations  of  silver  nitrate  may  be  employed. 
From  three  to  five  drops  of  a  two  to  five  per  cent,  solution  are  in- 
jected into  the  membranous  or  prostatic  urethra  every  third  or  fourth 
day. 

Should  the  incontinence  still  persist,  epidural  or  retro-rectal  injec- 
tions may  be  tried. 

The  epidural  injection  is  made  into  the  space  between  the  dura 
and  the  periosteal  lining  of  the  vertebral .  canal.  This  space  extends 
from  the  sacro-coccygeal  ligament  to  the  foramen  magnum,  at  which 
point  the  dura  and  periosteum  unite.  Laterally  the  epidural  space 
is  closed  at  the  intervertebral  foraminae.  A  colored  fluid  injected  into 
this  space  will  stop  abruptly  at  the  points  of  termination  mentioned 
and  remain  exclusively  intravertebral,  not  entering  the  cranium,  the 
subarachnoid  space,  nor  coming  in  contact  with  the  nerve  substance. 
If  the  injection  be  made  at  the  lowest  point  of  the  sacral  canal,  it  will 
stain  the  pelvic  cellular  tissue  and  the  ischio-rectai  fossse  because  there 
are  no  dural  adhesions  at  the  intervertebral  foramina  in  the  lower 
third  of  the  sacral  canal. 

About  one  or  two  centimetres  (.4  to  .8  of  an  inch)  above  the  inter- 
gluteal  fold,  is  the  flat  triangular  sacrococcygeal  space,  the  upper  limit 
or  base  being  formed  by  the  convex  bulging  ridge  of  the  first  sacral 
vertebra  terminating  at  the  lateral  sacral  cornua.  The  distance  be- 
tween this  space  and  the  tip  of  the  coccyx  is  about  six  and  one-half 
to  seven  centimetres  (two  and  one-half  to  three  inches).  In  stout 
individuals  digital  exploration  will  be  necessary  to  determine  the  exact 
location  of  this  space.  Its  mid-portion  is  the  best  site  for  the  injec- 
tion.    Through  a  skin  puncture  made  under  local  anaesthesia  by  a 


SYMPT03IAT0L0GY  OF  DISEASES  OF  URINAEY  TRACT.        327 

sharp-pointed  tenotome  the  needle  should  be  inserted  to  a  depth  of 
one  and  one-half  to  two  inches  (three  to  five  centimetres)  in  the  mid- 
line (to  avoid  injury  to  the  coccygeal  nerves  or  ganglia)  and  in  a  for- 
ward and  upward  direction.  As  the  sacro-coccygeal  ligament  is  punc- 
tured, its  density  is  readily  appreciated,  and  thereafter  the  tissues  hold 
the  needle  somewhat  rigidly. 

From  five  to  twenty  cubic  centimetres  of  normal  salt  solution  may 
be  given  three  times  a  week.  Some  cases  require  repeated  injections. 
A  remarkable  feature  in  the  reported  results  of  this  treatment  is  that 
excessive  desire  to  urinate  is  said  to  be  diminished  and  deficient  desire 
to  be  stimulated.  The  operation  is  rarely  painful  and  the  treatment 
if  carried  out  as  above  described  is  not  likely  to  do  harm. 

Jaboulay  commends  retro-rectal  injections  as  simpler  in  adminis- 
tration and  even  more  efficacious.  The  needle  is  introduced  at  the 
tip  of  the  coccyx  and  passed  vertically  upward  for  two  inches,  a  finger 
in  the  rectum  guarding  this  portion  of  the  bowel  against  puncture. 
Two  hundred  cubic  centimetres  of  normal  salt  solution  are  slowly 
injected  in  adults — about  quarter  the  quantity  in  children.  Some 
extraordinary  cures  are  reported,  the  cures  being  explained  on  the 
basis  of  a  mechanical  impression  on  the  hypogastric  plexus.  Should 
this  method  fail,  recourse  must  be  had  to  the  local  application  of  elec- 
tricity, and  this  should  be  continued  over  a  long  period, — from  six  to 
eight  months, — or  even  a  year. 

If  the  enuresis  is  purely  functional,  many  children  will  get  well, 
after  attention  to  their  general  hygiene,  if  they  abstain  from  liquids  in 
the  evening,  empty  the  bowels  and  bladder  before  going  to  bed,  and 
rise  once  during  the  night  to  micturate. 

Though  it  is  customary  to  advise  as  the  next  means  of  treatment 
the  administration  of  drugs,  we  are  in  general  opposed  to  this,  be- 
lieving that  better  results  are  more  promptly  attained  by  local  treat- 
ment, provided  the  attendant  is  fairly  skilful  in  the  use  of  urethral 
instruments  and  recognizes  the  importance  of  thorough  cleanliness 
in  all  his  manipulations. 

When  the  enuresis  has  lasted  past  the  age  of  puberty,  the  best 
results  will  be  obtained  from  the  use  of  full-calibre  sounds,  instilla- 
tions, and  possibly  from  epidural  or  presacral  injections. 

Incontinence  with  Lesions  of  the  Urinary  Tract. — When 
enuresis  is  not  functional,  but  is  due  to  hypersecretion  or  to  tuber- 
culosis, for  instance,  the  cause  must  receive  treatment. 

Incontinence  without  retention  of  urine  is  necessarily  dependent 
upon  a  patulous  condition  of  the  sphincter.  This  may  be  caused 
by  lodgement  of  an  irregularly  shaped  stone,  by  which  the  vesical 


328  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

sphincter  is  kept  open  but  is  not  occluded.  This  form  of  inconti- 
nence, Guyon  states,  is  observed  only  in  children. 

Such  a  condition  should  be  treated  by  pushing  the  stone  back 
into  the  bladder  and  removing  it  by  litholapaxy,  or,  in  case  this  is 
impossible,  by  perineal  section. 

Tubercular  ulceration  may  infiltrate  and  entirely  destroy  the 
vesical  sphincters,  resulting  in  an  intractable  form  of  incontinence, 
the  nature  of  which  is  rarely  doubtful,  since  it  develops  only  in  the 
advanced  stage  of  vesical  tuberculosis. 

Incontinence  due  to  contusion  or  overstretching  of  the  prostate, 
such  as  occurs  in  perineal  lithotrity  or  in  digital  examination  of  the 
female  bladder  through  the  urethra,  may  persist  indefinitely.  To- 
nicity of  the  sphincter  muscle  is  best  restored  by  the  application  of 
local  electricity. 

Incontinence  due  to  fistulous  opening  of  the  bladder  is  elsewhere 
discussed. 

Guyon  describes  under  the  heading  urethral  insufficiency  a  form 
of  incontinence  characterized  by  involuntary  escape  of  urine  caused 
by  the  slightest  muscular  effort,  such  as  coughing,  laughing,  or  strain- 
ing, or  even  by  standing.  The  urethra  is  perfectly  normal.  Women 
especially  suffer  from  this  form  of  incontinence,  because  of  atonicity 
of  the  vesica]  sphincter.  Sometimes  it  is  seen  in  men  after  stretch- 
ing of  the  prostatic  urethra  or  the  use  of  very  large  sounds. 

Electricity  supplemented  by  instillations  is  serviceable  in  these 
cases.  In  women,  when  this  method  of  treatment  fails  and  the  escape 
of  urine  is  profuse,  as  a  last  resort  the  urethra  may  be  freed  by  dis- 
section through  the  greater  part  of  its  length,  given  a  half  or  a  three- 
fourths  twist  in  its  long  axis,  and  sewed  in  this  position. 

Incontinence  of  retention  is  the  ordinary  form  of  incontinence^ 
and  is  observed  particularly  in  those  suffering  from  enlarged  prostate 
or  from  stricture.  Distinction  should  be  made  between  this  form  of 
incontinence,  in  which  the  urine  dribbles  without  either  the  volition  or 
the  consciousness  of  the  patient,  and  the  urgent,  imperious  urination 
of  cystitis  or  of  irritable  bladder.  The  true  nature  of  this  incon- 
tinence is  of  course  at  once  recognized  by  vesical  palpation,  and  the 
nature  of  the  obstruction  is  determined  by  the  previous  history  and 
by  urethral  examination. 

When  in  this  form  of  incontinence  the  urethra  is  patulous  and  is 
of  normal  length,  the  cause  must  be  sought  in  the  nervous  system. 

As  for  treatment,  this  is  directed  to  the  relief  of  the  retention 
rather  th5,n  to  the  incontinence,  and  has  been  already  discussed. 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINxVRY  TRACT.        329 

HJEMATURIA. 

The  vascularity  of  the  urinary  tract  and  the  readiness  with  which 
it  becomes  engorged  are  reasons  why  blood  is  so  frequently  found 
mixed  with  the  urine.  The  bleeding  may  be  profuse  and  from  ap- 
parently slight  causes.  Guy  on  gives  the  exciting  causes  of  hemor- 
rhage as  traumatism,  congestion,  inflammation,  organic  disease,  foreign 
bodies ;  or,  as  a  still  more  simple  classification,  the  bleeding  may  be 
mechanical,  inflammatory  or  congestive,  or  organic. 

It  is  important  not  to  regard  the  color  of  the  urine  as  sufficient 
evidence  of  the  presence  of  blood,  since  an  excess  of  uric  acid  or  bile- 
pigments,  or  the  ingestion  of  senna,  rhubarb,  or  carboKc  acid,  or  the 
presence  of  haemoglobin,  will  give  a  reddish  or  a  brownish  tint,  abso- 
lutely like  that  due  to  the  presence  of  blood. 

It  is  upon  microscopic,  spectroscopic,  and  chemical  examination  that 
the  diagnosis  must  be  founded.  (See  page  346.)  The  color  may  vary 
from  a  rosy  red  to  a  deep  brown.  When  together  with  blood  there  is 
pus,  as  in  cases  of  acute  and  chronic  cystitis,  the  blood  may  be  found 
entirely  in  the  sediment,  being  somewhat  irregularly  mixed  with  this 
deposit  and  imparting  none  of  its  color  to  the  supernatant  liquid. 

The  lower  the  specific  gravity  of  the  urine  the  more  readily  the 
blood  dissolves  in  it,  and  hence  the  slower  the  clot-formation.  This 
fact  has  an  important  bearing  on  treatment,  suggesting  the  use  of 
diluents  when  there  is  danger  of  retention  from  clotting. 

The  clots  which  are  passed  have  no  diagnostic  significance,  with 
one  exception :  a  long,  thin,  rounded  clot  in  the  shape  of  a  small 
earthworm  must  necessarily  have  been  moulded  in  the  ureter,  and 
hence  indicates  either  renal  or  ureteric  origin  of  bleeding.  Short 
cylindrical  clots  have  not  the  same  significance,  since  they  may  have 
been  formed  in  the  urethra. 

The  clots  may  be  dark  red  and  readily  broken  up,  or  tough  and 
yellowish  red,  suggesting  the  appearance  of  organized  tissue.  A 
microscopic  examination  is  required  to  distinguish  these  fibrinous 
clots  from  fragments  of  neoplasm. 

Since  congestion  is  so  important  a  predisposing  condition  to  haem- 
aturia,  it  sometimes  happens  that  symptoms  of  this  engorgement  will 
precede  hemorrhage.  There  may  be  a  sensation  of  weight  and  dis- 
comfort rather  than  actual  suffering,  or  an  attack  of  kidney  colic. 
These  pains  are  of  brief  duration,  are  felt  in  the  region  of  the  kidneys 
or  along  the  ureters,  and  strongly  point  to  the  renal  origin  of  bleeding. 
Such  premonitory  pains  are  rarely  felt  in  bleeding  from  the  bladder. 

The  source  of  hsematuria  is  sometimes  indicated  by  the  color  of 
the  blood  or  by  th(?  time  of  its  appearance  in  the  urine. 


330  GENITO-UKINAKY  DISEASES  AND  SYPHILIS. 

Blood  which  appears  with  the  first  jet  of  urine  (initial  hsematuria), 
the  remainder  of  the  liquid  remaining  clear,  must  necessarily  come 
from  some  portion  of  the  urethra.  In  this  case  the  quantity  of  blood 
must  be  very  slight,  otherwise  it  would  escape  externally  if  it  came 
from  the  anterior  urethra,  or  would  flow  back  into  thebladder  if  from 
the  prostatic  urethra.  Usually  when  the  blood  comes  from  the  pros- 
tate there  is  also  terminal  hsematuria ;  that  is,  the  last  portion  of  the 
urine  .may  contain  blood,  or  almost  pure  blood  may  be  passed. 

When  all  the  urine  contains  blood,  but  that  last  passed  contains 
the  greatest  quantity,  the  last  few  drops  micturated  being  nearly  pure 
bright  blood,  the  probability  of  the  vesical  or  prostatic  origin-  of  the 
bleeding  is  very  strong.  If  blood  is  passed  only  at  the  end  of  mic- 
turition (terminal  hsematuria),  the  blood  must  necessarily  come  from 
either  the  bladder  or  the  prostatic  urethra.  It  is  particularly  in  pros- 
tato-cystitis  that  terminal  hgematuria  is  observed.  The  bleeding  is 
not  profuse,  and  is  associated  with  other  symptoms  of  cystitis,  notably 
frequency  and  urgency.  In  severe  injury  to  the  kidney  or  malignant 
growth  of  this  organ,  the  blood  may  be  bright  red  and  the  hsematuria 
may  appear  to  be  terminal.  When  bleeding  follows  traumatism  its 
origin  will  often  be  indicated  by  the  character  and  seat  of  the  injury. 
Thus,  in  case  of  gunshot  wound  in  the  lumbar  region  the  appearance 
of  blood  in  the  urine  would  necessarily  indicate  injury  of  the  kidney, 
while  haematuria  following  a  kick  in  the  hypogastric  region  would 
suggest  contusion  or  rupture  of  the  bladder.  Blood  escaping  inde- 
pendently of  the  act  of  micturition  must  come  from  some  part  of  the 
anterior  urethra. 

The  quantity  of  blood  in  the  urine  is  of  some  diagnostic  value.  If 
the  bleeding  is  apparently  causeless,  intermittent,  and  profuse,  it  is 
usually  due  to  renal  or  vesical  tumors,  though  tropical  parasites  in  the 
urinary  tract,  notably  the  distoma,  may  cause  severe  bleeding. 

Bleeding  may  be  caused  by  cantharides,  turpentine,  mercury,  or 
the  ingestion  of  certain  foods.  B.enal  telangiectasis  has  been  reported 
as  a  cause  for  blood  in  the  urine,  and  this  symptom  regularly  follows 
renal  thrombosis  and  infarcts. 

Blood  may  appear  in  the  urine  in  the  course  of  hsemophilia,  or 
because  of  parasites  (filaria  sanguinis  hominis),  closely  simulating  the 
surgical  forms  of  haematuria.  When  it  is  due  to  infectious  fevers, 
such  as  variola  or  scarlatina,  to  dyscrasise,  such  as  scurvy  or  pur- 
pura, or  to  hysteria,  it  is  not  likely  to  be  confounded  with  haematuria 
which  is  mainly  local  in  origin. 

When  haematuria  follows  sudden  muscular  action  or  apparently 
insufficient   violence,    this    is    probably   due    to    the    presence    of  a 


SYMPTOMATOLOGY  OF  DISEASES  OF  URINARY  TRACT.       331 

hitherto  unsuspected  lesion.  The  conditions  which  commonly  pre- 
cede the  bleeding  are  tumor,  tuberculosis,  and  nephritis. 

In  general  terms,  when  urination  causes  bleeding,  stone,  tumor, 
or  tuberculosis  may  be  suspected.  Hsematuria  due  to  new  growth, 
whether  this  be  of  the  bladder  or  of  the  kidney,  is  usually  profuse, 
apparently  causeless,  intermittent,  made  worse  by  exercise,  not 
cured  by  rest.  The  freest  bleeding  may  come  from  the  smallest 
papilloma. 

A  tumor,  if  not  placed  near  the  vesical  neck,  may  occasion  no 
symptoms  other  than  hsematuria,  and  in  its  early  stages  may  readily 
escape  detection  by  palpation.  The  renal  origin  may  be  suspected 
after  elimination  of  the  vesical  source  of  the  hemorrhage.  This  sus- 
picion will  be  changed  to  a  surety  if  associated  with  the  bleeding,  or 
preceding  it,  there  have  been  attacks  of  renal  colic. 

Guyon  calls  attention  to  a  symptom  which  may  aid  in  making  a 
differential  diagnosis.  In  kidney  tumor  the  blood  sometimes  suddenly 
disappears,  to  return  as  suddenly.  These  alternations  are  repeated 
at  short  intervals.  It  may  be  for  only  a  few  hours  that  the  urine  re- 
mains limpid,  and  then  the  blood  again  appears,  often  containing  a 
clot  moulded  in  the  ureter.  This  sudden  clearing  of  the  urine  is  due 
to  temporary  blocking  of  the  ureter;  the  bladder  then  contains  only 
the  excretion  of  the  healthy  kidney.  "When,  together  with  blood, 
renal  blood-casts  are  found,  the  origin  of  the  bleeding  is  positively 
indicated.     Attacks  of  renal  colic  are  equally  characteristic. 

In  determining  the  source  of  bleeding,  evidence  afforded  by  analysis 
of  associated  symptoms  and  by  direct  examination  must  be  carefully- 
considered.  If  the  bladder  is  sufficiently  affected  to  cause  bleeding 
from  its  mucous  membrane  there  will  usually  be  frequency,  urgency, 
and  pain  if  the  case  be  inflammatory,  mechanical,  or  traumatic  ;  or  a 
bimanual  examination  will  show  some  alteration  in  the  vesical  walls 
or  in  the  prostate  if  there  be  infiltration  or  tumor. 

Vesical  tumors  are  usually  complicated  by  cystitis,  due  to  cathe- 
terization. This  is  not  so  common  in  renal  tumors,  or,  if  it  develops, 
follows  the  bleeding  by  a  longer  interval,  and  is  much  more  amenable 
to  treatment. 

The  first  symptom  of  tumor  of  the  bladder  is  haematuria,  unless 
the  growth  is  placed  near  the  vesical  orifice,  in  which  case  frequent 
micturition  may  precede  the  appearance  of  blood.     (Fenwick.) 

The  bleeding  from  chronic  Bright's  disease  is  moderate ;  excep- 
tionally it  is  intermittent  and  profuse.  Other  symptoms  of  the  dis- 
ease, and  particularly  the  results  of  urinary  examination,  suggest 
the  cause  of  hemorrhage.     The  hemorrhage  of  syphilitic  glomerular 


332  GENITO-UEIlsrAEY   DISEASES   AND   SYPHILIS. 

nephritis  can  be  diagnosed  only  by  the  associated  symptoms  of  the 
disease. 

Haematuria  of  renal  tuberculosis  is  characterized  by  pain,  often 
amounting  to  true  renal  colic,  pus  in  the  urine,  which  persists,  and  a 
moderate  amount  of  blood,  appearing  intermittently.  Renal  calculus 
also  occasions  but  a  slight  amount  of  bleeding  and  causes  pain  in 
the  back  which  is  reflected  in  various  directions.  The  bleeding,  the 
attacks  of  colic,  and  the  pain  are  reheved  by  rest.  This  is  also  true  of 
the  hsematuria  thus  associated  with  obstructive  hydronephrosis.  The 
same  amelioration  is  not  noted  in  either  tuberculosis  or  new  growths. 

Stone  in  the  bladder,  in  addition  to  the  typical  symptoms,  causes 
blood  in  moderate  quantity.  At  times  when  the  stone  is  complicated 
by  enlarged  prostate  blood  is  the  only  symptom.  Bleeding  from 
tuberculosis  of  the  bladder  is  also  slight,  occurring  particularly  at  the 
end  of  micturition.  The  symptoms  are  much  like  those  of  stone. 
Acute  posterior  urethritis  also  occasions  bleeding  at  the  end  of  urina- 
tion. The  effect  of  rest  upon  symptoms  of  stone  is  so  marked  and 
immediate  that  this  is  a  diagnostic  sign  of  distinct  value.  Haematuria 
which  is  not  materially  influenced  by  either  exercise  or  rest  is  usually 
due  to  tuberculosis,  new  growth,  or  acute  inflammation.  The  renal 
and  vesical  hemorrhage  following  catheterization  of  an  overfull  bladder 
has  already  been  discussed ;  acute  cystitis  may  exceptionally  cause 
such  free  bleeding  that  the  term  hemorrhagic  is  applicable.  A  few 
reported  cases  seem  to  prove  that  varicose  veins  or  atheromatous 
arteries  may  by  rupturing  give  rise  to  serious,  even  fatal,  hemorrhage. 
Enlarged  prostate  may  also  cause  spontaneous  bleeding. 

The  flnal  determination  as  to  the  source  of  haematuria  must  de- 
pend upon  cystoscopic  examination.  Practically  it  is  only  in  cases  of 
malignant  growth,  or  possibly  in  those  of  tuberculosis,  that  associated 
symptoms  fail  to  suggest  the  origin  of  the  blood.  The  examination 
may  be  made  either  in  the  interval  between  attacks  or  during  the 
course  of  the  bleeding,  but  if  the  hemorrhage  is  even  moderate  in 
quantity  and  from  the  vesical  region,  nothing  can  be  seen,  since  the 
fluid  injected  into  the  bladder  at  once  becomes  opaque  from  admix- 
ture with  blood.  If  the  bleeding  is  moderate  and  of  renal  origin,  by 
using  the  irrigating  cystoscope  the  blood  may  be  seen  escaping  from 
the  ureter.  The  bladder  should  first  be  emptied  of  its  bloody  urine^ 
and  then  filled  quickly  with  clear  fluid.  A  bloody  jet  may  be  seen 
escaping  from  the  ureter  before  the  liquid  contained  in  the  bladder 
becomes  too  deeply  stained  to  allow  of  further  examination. 

It  is  always  best  to  make  a  cystoscopic  examination  in  the  inter- 
vals of  bleeding,  but  when  hemorrhage  is  supposed  to  be  of  renal 


SYMPTOMATOLOGY  OF  DISEASES  OF  UKINARY  TRACT.        333 

origin  and  is  slight  in  amount,  it  will  be  impossible  to  determine 
from  which  ureter  the  blood  comes  unless  the  cystoscope  is  used 
while  bleeding  is  still  going  on. 

If  an  examination  made  after  bleeding  has  ceased  shows  that  the 
bladder  is  healthy,  this  of  course  points  to  the  renal  origin  of  bleed- 
ing. If,  on  repeated  trials,  the  urine  previously  having  been  nearly 
or  quite  free  from  blood,  the  introduction  of  the  cystoscope  at  once 
occasions  such  free  hemorrhage  that  examination  cannot  be  made, 
this  is  itself  indicative  of  the  vesical  origin  of  the  hemorrhage  and 
almost  positively  points  to  new  growth. 

Treatment  of  Hcematuria. — During  an  acute  attack  of  bleeding, 
whatever  be  its  cause,  rest  in  bed,  liquid  diet,  preferably  milk  and 
buttermilk,  diluent  drinks,  for  the  purpose  of  lessening  the  tendency 
to  coagulation,  and  a  solvent  condition  of  the  bowels  procured  by 
enemata  are  advisable  on  general  principles. 

Medication  by  the  mouth  is  of  little  value.  Guyon  speaks  well 
of  turpentine.  This  may  be  given  in  three-drop  doses  hourly  for  six 
or  eight  hours,  preferably  well  diluted  in  the  form  of  a  mucilaginous 
emulsion.  Ergot  and  ergotin  have  been  strongly  commended,  and 
may  be  given  in  full  doses, — a  drachm  of  the  former  or  five  grains 
of  the  latter  at  hourly  intervals.  Oil  of  erigeron  also  seems  service- 
able at  times, — five  drops  in  an  emulsion  every  h"our.  Gallic  acid  is 
credited  with  some  haemostatic  powers.  It  may  be  given  in  ten-grain 
doses  every  hour. 

When  the  bleeding  is  profuse  and  threatening  to  life,  and  there 
are  associated  with  it  restlessness  and  anxiety,  injection  of  human 
blood  serum  is  indicated.  If  there  be  tenesmus,  pain,  and  over- 
distention  of  the  bladder  from  clotting  and  urethral  obstruction,  a 
full  dose  of  morphine  is  indicated,  and  emptying  the  bladder 
by  the  catheter  and  suction  syringe.  This  may  be  followed  by  irri- 
gation with  a  hot  astringent  antiseptic  solution,  such  as  silver  nitrate 
1  to  2000,  fluid  extract  of  hydrastis  (colorless)  an  ounce  to  one  pint, 
after  such  irrigation  there  may  be  injected  a  half  ounce  of  adrenalin 
chloride  1  to  5000  or  the  same  quantity  of  antipyrin  solution,  Ave  per 
cent.  Antipyrin  possesses  distinct  value  as  an  analgesic,  and  is  credited 
with  being  a  powerful  haemostatic.  Continuous  catheterization  is  in- 
dicated till  the  bleeding  ceases.  If  the  use  of  the  catheter  is  impracti- 
cable, perineal  cystotomy  is  the  operation  of  choice,  followed  by  the 
removal  of  clots,  and  the  insertion  of  a  large  drainage-tube. 

Most  minute  antiseptic  precautions  must  be  observed  in  all  these 
manipulations,  since  the  urinary  tract  in  case  of  bleeding  is  peculiarly 
susceptible  to  infection,  which  if  once  started  is  liable  to  resist  treat- 


334  GENITO-IJEINAKY   DISEASES   AND   SYPHILIS. 

ment  and  extend  rapidly  to  the  kidneys.  The  dangers  are  particu- 
larly great  in  cases  of  neoplasm. 

The  bleeding  of  prostatics,  dependent  upon  the  intense  engorge- 
ment which  comphcates  retention,  if  profuse  and  threatening  to  life, 
is  best  treated  by  evacuating  the  blood  by  means  of  a  catheter  and 
syringe  and  keeping  the  bladder  empty  by  the  retained  catheter.  If 
the  clots  cannot  be  removed  in  this  way,  perineal  or  suprapubic  cys- 
totomy is  indicated.  If  bleeding  persists,  pressure  above  the  pubis, 
applied  by  means  of  compresses,  must  be  tried. 

Hemorrhage  from  prostatitis  and  prostato-cystitis  relieves  engorge- 
ment. If  moderate,  it  is  often  benefited  by  balsams  combined  with 
diluents  and  by  the  rectal  use  of  opium.  The  same  treatment  is 
applicable  to  tubercular  cystitis.  Renal  hemorrhage,  if  persistent  and 
threatening  to  life,  should  be  treated  by  exploratory  nephrotomy.  This 
operation  is  often  curative  even  though  no  cause  be  found  for  the 
bleeding.  Further  detailed  treatment  of  hsematuria  is  given  in  the 
sections  devoted  to  the  pathological  conditions  which  cause  it. 

EXAMINATION    OF   THE   URINE. 

Alterations  in  the  urine  are  clinically  reliable  only  when  the  diet, 
regimen,  and  life-conditions  of  the  patient  have  been  taken  into  careful 
consideration.  Under  certain  conditions  the  diet  alone  may  be  re- 
sponsible for  an  albuminuria  or  a  glycosuria ;  and  it  would  be  obviously 
misleading  to  make  a  quantitative  determination  of  urea  or  of  lime,  for 
example,  without  knowing  the  character  of  the  patient's  food. 

Alterations  in  the  Quantity  of  Urine. — The  normal  quantity 
may  vary  from  one  to  five  pints  per  diem,  depending  upon  various 
obvious  conditions  ;  the  average  is  from  two  to  three  pints.  The 
quantitative  variations  are  classified  under  the  headings  polyuria, 
oliguria,  and  anuria. 

Polyuria  is  an  excess  in  the  total  bulk  of  urine  beyond  the  physio- 
logical maximum,  and  the  excess  may  reach  two  gallons,  or  even 
more.  Polyuria  occurs  in  diabetes  mellitus,  insipidus,  and  phos- 
phaticus ;  in  interstitial  nephritis  and  amyloid  degeneration  of  the 
kidneys  ;  in  cardiac  hypertrophy  ;  in  pyelitis  ;  following  thermal  crises 
and  during  convalescence ;  and  in  many  functional  and  organic  dis- 
eases of  the  nervous  system,  such  as  conditions  of  excitement,  nervous 
tension,  and  overwork.  Periodical  polyuria  is  observed  during  the 
absorption  of  large  exudations,  and  is  sometimes  a  suggestive  symptom 
of  hydronephrosis  or  obstructing  renal  calculus. 

Oliguria,  or  quantitative  diminution  of  the  urine,  is  present  in 
fevers  and  infections ;  excessive  sweating   or   prolonged    diarrhoeas ; 


EXAMINATION   OF    THE   URINE.  335 

when  the  cu*culation  is  disturbed  ;  or  when  local  pressure  upon  renal 
vessels  by  tumor,  ascites,  or  torsion  interfere  with  the  renal  circulation  ; 
in  acute  glomerulo-nephritis  and  acute  and  chronic  parenchymatous 
and  septic  or  suppurative  nephritis  ;  in  many  cases  of  hydronephrosis, 
renal  calculus,  tuberculosis,  or  malignant  disease  of  the  kidneys  ;  in 
some  nervous  diseases,  when  transudates  or  exudates  are  forming; 
and  after  anassthetics,  where  nephritis  is  present. 

Anuria  is  the  complete  suppression  of  urine.  There  are  two 
varieties.     (See  page  293.) 

In  one  the  main  fault  Kes  in  the  renal  structure  ;  it  occurs  in 
some  cases  of  nephritis,  especially  the  post-scarlatinal  nephritis,  in 
the  intoxications  of  the  infectious  diseases,  especially  cholera,  and  in 
profuse  diarrhoeas.  Exceptionally  it  is  due  to  the  pressure  of  a  tumor 
or  of  ascites,  or  may  be  produced  by  poisons,  such  as  cantharides. 
In  these  cases  the  symptoms  of  uraemia  appear  early. 

The  second  variety  of  anuria  is  due  to  reflex  inhibition.  It  is 
seen  in  hysteria  and  in  other  functional  and  organic  nervous  dis- 
eases. Apparently  it  is  shown  that  a  calculus  by  blocking  one  ureter 
or  irritating  the  pelvis  of  one  kidney  may  cause  complete  bilateral 
suppression,  and  complete  suppression  has  been  produced  by  torsion 
of  the  vessels  of  one  floating  kidney.  It  also  occurs  in  intestinal  stran- 
gulation or  other  obstruction.  In  these  cases  the  symptoms  of  uraemia 
are  for  a  long  time  deferred. 

Alterations  in  the  Specific  G-ravity. — These  are  important, 
because,  if  the  total  quantity  of  urine  be  borne  in  mind,  they  are 
often  an  index  of  the  quantity  of  metabolic  excrementa. 

The  normal  specific  gravity  may  vary  from  1010  to  1030,  averaging 
about  1018  to  1020. 

With  a  normal  elimination  of  the  metabolic  products  the  specific 
gravity  will  be  high  in  oliguria  and  low  in  polyuria  in  proportion  to 
the  concentration  or  dilution.  Low  specific  gravity  of  the  urine  in 
parenchymatous  nephritis  is  a  sign  of-  diminished  elimination  of  the 
organic  constituents ;  the  low  specific  gravity  in  interstitial  nephritis 
and  in  diabetes  insipidus  is  largely  due  to  dilution.  In  chronic  ne- 
phritis a  sudden  fall  in  specific  gravity  is  often  a  prodrome  of  uraemia. 
The  specific  gravity  is  reduced  by  decomposition  within  the  bladder. 
The  high  specific  gravity  in  diabetes  mellitus  is  not  always  propor- 
tionate to  the  amount  of  sugar  in  the  urine. 

Alterations  in  Color. — Normally  the  urine  is  a  clear  straw-yel- 
low. The  color  of  the  normal  urine  is  largely  due  to  urobilin  and 
uroerythrin,  and  varies  considerably.  The  color  in  polyuria  is  gen- 
erally pale,  in  oliguria  dark.     It  is  dark  in  most  febrile  conditions. 


336  GENITO-rRIXARY   DISEASES    AIS"©   SYPHILIS. 

Bile  gives  it  a  brownish-yellow  color,  often  with  a  tinge  of  green ;  the 
foam  formed  by  shaking  it  is  yellow, — a  condition,  however,  which 
may  be  produced  by  an  excess  of  urobilin. 

An  excess  of  the  aromatic  sulphates  gives  the  urine  a  deep-brown 
color,  also  seen  in  cases  of  pathological  urobilin.  Blood  tinges  the 
urine  from  a  pale  pink  to  a  deep  red. 

Alkaline  urine  is  a  cloudy,  flocculent  yellow.  A  great  deal  of  pus 
produces  a  milky  opacity.  The  appearance  in  chyluria  is  that  of 
thin  cream.  Acid  urine  is  usually  clear ;  cloudiness  due  to  salts  of 
uric  acid  clears  on  gentle  heating. 

Carbolic  acid  and  the  allied  coal-tar  compounds  appear  in  the  urine 
in  part  as  hydrochmone,  giving  a  smoky  black  color ;  others,  as  the 
coal-tar  antipyretics,  sulphonal,  and  the  allied  hypnotics,  may  produce 
hsematoporphyrinuria,  causing  a  pink  or  red  color.  Santonin  produces 
a  yellowish-green  color ;  rhubarb  and  senna  a  brown  or  reddish  tint. 

Alterations  in  Reaction. — The  reaction  of  the  total  day's  urine 
is  faintly  acid,  due  to  acid  phosphates  and  urates.  There  is  generally 
an  alkaline  wave  at  the  height  of  digestion.  The  acidity  is  especially 
increased  in  fever,  in  diabetes,  and  often  in  the  blood  dyscrasiae,  after 
prolonged  muscular  exercise. 

The  reaction  is  alkaline  in  phosphaturia,  and  in  all  conditions  as- 
sociated with  decomposition  of  the  urea  within  the  tract,  particularly 
in  cystitis.  An  animal  diet  increases  the  acidity,  a  vegetable  diet 
decreases  it. 

Wlien  large  transudations  are  being  formed,  the  acidity  of  the 
urine  is  increased ;  it  is  decreased  when  the  transudates  are  being  ab- 
sorbed. The  urine  is  alkaline  during  an  attack  of  paroxysmal  hsemo- 
globinuria  and  following  serous  transfusions  or  large  subcutaneous  or 
intravenous  saline  injections.  There  are  some  obscure  alterations  of 
metabolism  in  which  the  urine  is  alkaline. 

All  the  mineral  acids  and  most  organic  acids,  especially  boric  and 
benzoic  acids,  increase  the  acidity  of  the  urine.  The  hydrates  and 
carbonates  of  sodium,  potassium,  calcium,  and  magnesium,  and  the 
salts  of  the  vegetable  acids  which  are  eliminated  as  alkahne  carbon- 
ates,— acetic,  citric,  tartaric  acids,  etc., — diminish  the  acidity  or  render 
the  urine  alkaline. 

Quantitative  Alterations  of  Normal  Constituents. — Chlo- 
rides.— The  chlorides  in  the  urine  are  of  sodium,  potassium,  ammo- 
nium, and  magnesium.  The  amount  on  a  mixed  diet  corresponds  to 
from  one  and. a  fourth  to  three  drachms  of  sodium  chloride  daily. 

The  .elimination  is  increased  by  excessive  exercise  ;  in  hsematuria ; 
following  the  absorption  of  large  exudates  ;  in  poisoning  by  pyrogallic 


EXAMIJfATION    OF   THE    UEINE.  337 

acid,  methyl  chloride,  and  all  other  agents  which  disintegrate  the 
blood ;  in  malaria  and  acute  interstitial  hepatitis  ;  and  following  a 
chloroform  narcosis.  The  elimination  is  decreased  in  fevers,  and  espe- 
cially in  the  exudative  stages  of  pneumonia  and  the  acute  serous 
inflammations ;  in  poisoning  by  phosphorus  and  carbon  monoxide ; 
in  some  cases  of  chronic  nephritis  ;  in  dilatation  of  the  stomach ;  in 
all  cases  of  profuse  intestinal  discharges  ;  in  inanition  ;  and  in  hunger. 
The  chlorides  are  estimated  as  silver  chloride  by  the  volumetric  or 
the  gravimetric  method. 

Sulphur. — Sulphur  exists  in  the  urine  mainly  as  preformed  sul- 
phates of  sodium,  potassium,  and  calcium,  as  the  ether  sulphates,  and 
as  neutral  sulphur.  The  total  quantity  corresponds  to  from  one  and 
five- tenths  to  three  grammes  of  sulphuric  oxide  per  diem ;  the  ratio 
of  the  preformed  to  the  ether  sulphates  varies  from  ten  to  one  to 
eighteen  to  one. 

The  aromatic  sulphates  are  strikingly  increased  in  many  con- 
ditions :  in  most  infectious  fevers,  and  especially  in  advanced  tuber- 
culosis ;  in  intestinal  putrefaction  of  all  kinds,  and  in  intestinal 
obstructions ;  in  internal  suppuration,  especially  of  the  large  serous 
membranes,  in  internal  gangrene,  and  in  rapid  muscular  atrophy  due 
to  any  cause  ;  in  diabetes ;  and  in  poisoning  by  the  phenol  com- 
pounds, thymol,  ichthyol,  camphor,  phosphorus,  the  salicylates,  and 
the  aromatic  oils,  as  terebene,  etc. 

Indican  is  one  of  the  ether  sulphates  (indoxyl-sulphuric  acid),  and, 
as  it  possesses  a  striknig  reaction,  it  has  been  largely  taken  as  the 
most  available  clinical  representative  of  this  group.  A  convenient 
test  for  indican  is  to  add  to  ten  cubic  centimetres  of  urine  one  or  two 
cubic  centimetres  of  a  twenty  per  cent,  aqueous  solution  of  plumbic 
subacetate,  and  filter ;  to  the  filtrate  is  added  an  equal  volume  of  a 
one-half  per  cent,  solution  of  ferric  chloride  in  strong  hydrochloric 
acid,  and  the  mixture  thoroughly  shaken,  when  the  indigo-blue  re- 
action appears,  and  the  coloring  matter  can  be  extracted  with  chloro- 
form. If  intestinal  conditions  can  be  excluded^  a  strong  reaction  of 
indican  can  be  taken  as  evidence  of  rapid  disintegration  of  albumen 
somewhere  in  the  system. 

The  neutral  sulphur  constitutes  about  fifteen  per  cent,  of  the  total 
sulphur ;  it  consists  of  organic  compounds.  It  is  strikingly  increased 
in  all  cases  of  obstruction  of  the  common  bile-duct,  and  to  a  less 
extent  in  non-obstructive  jaundice. 

Sulphur  may  also  appear  in  the  urine  in  the  form  of  sulphuretted 
hydrogen.  It  may  enter  the  urine  through  fistulous  tracts,  may  pene- 
trate the  bladder  from  adjacent  necrotic  areas,  and  may  be  evolved 

22 


338  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

ill  the  urine  of  severe  cases  of  cystitis  tlirough  the  action  of  a  special 
bacterium. 

The  amount  of  total  sulphur  should  be  estimated  as  barium 
sulphate ;  the  aromatic  sulphates  are  estimated  by  the  Baumann- 
Salkowski  method ;  the  presence  of  sulphuretted  hydrogen  can  be 
determined  readily  by  its  odor  and  its  reactions  with  the  metals. 

Phosphates. — Phosphates  are  present  as  the  diacid,  acid,  and 
simple  sodium,  potassium,  calcium,  and  magnesium  phosphates,  the 
ratio  of  the  alkahne  to  the  earthy  phosphates  being  as  2.5  to  1.  The 
total  amount  corresponds  to  from  three  to  four  grammes  of  phosphoric 
oxide  daily.  The  acid  salts  are  most  soluble,  the  basic  least  of  all. 
True  phosphaturia,  an  actual  increase  in  the  elimination  of  phos- 
phoric oxide,  is  very  rare,  though  it  does  occur  in  some  cases  of 
obscure  diabetes  phosphaticus,  in  saccharine  and  insipid  diabetes,  in 
meningitis,  in  phosphorus  poisoning,  and  in  tuberculous  bone  disease. 
An  excess  does  not  occur  in  rachitis  nor  in  osteomalacia. 

There  is  a  form  of  so-called  phosphaturia  with  alkaline  urine,  and 
the  consequent  precipitation  of  the  phosphates,  not  connected  with 
cystitis  or  other  inflammatory  condition :  while  it  is  quite  certain  that 
this  is  not  dependent  on  an  excess  of  eliminated  phosphates,  it  is  not 
known  whether  it  is  caused  by  an  increased  alkalinity  of  the  blood 
(which  may  be  due  to  the  diet)  or  to  a  reflex  secretive  anomaly  of 
the  kidneys  secondary  to  some  functional  neurosis.  It  is  especially 
seen  in  neurasthenics  with  gastric  disturbances.  The  phosphates  are 
of  surgical  interest  because  of  their  precipitation  by  the  alkaline  urine 
of  cystitis  and  the  relation  of  the  sediment  to  calculus. 

The  total  phosphates  are  estimated  by  titration  with  uranium 
nitrate.  The  phosphatic  precipitate  of  alkaline  urine  has  a  whitish 
color,  and  is  dissolved  by  the  addition  of  sufficient  acid  to  render  the 
urine  acid  in  reaction. 

Carbonates. — There  is  carbon  dioxide  in  solution  in  the  urine, 
and  the  alkaline  calcium,  magnesium,  and  ammonium  carbonates  exist 
in  miimte  quantities.  They  are  increased  by  fever,  by  a  fruit  or  vege- 
table diet,  and  particularly  in  the  alkaline  urine  of  cystitis,  when  the 
carbon  dioxide  is  derived  from  the  decomposition  of  urea. 

Sodium  is  present  in  the  urine  to  the  extent  of  from  four  to  six 
grammes  (estimated  as  oxide)  daily.  It  is  especially  decreased  in 
fevers,  and  is  increased  in  haematuria. 

Potassium. — The  urinary  elimination  of  potassium  averages  two  to 
three  grammes  daily.  It  is  not  much  affected  by  fevers,  but  it  is 
markedly  increased  in  conditions  of  rapid  breaking  down  of  tissues,  as 
acute  yellow  atrophy  of  the  liver,  internal  suppurations,  and  hagmaturia. 


EXAMINATION   OF   THE   UKINE.  339 

Ammonia. — The  quantity  of  ammonia  eliminated  daily  is  from  one- 
half  to  one  gramme ;'  this  is  much  increased  in  fever,  in  most  hepatic 
diseases,  and  in  diabetes.  Very  large  amounts  of  ammonia  are  formed 
in  the  alkaline  decomposition  of  cystitis. 

Magnesium  and  calcium  are  eliminated  to  the  extent  of  0.12* gramme 
and  0.25  gramme  respectively  daily.  The  proportional  excretion  is 
less  in  infancy,  in  old  age,  in  pregnancy,  in  fevers,  and  in  profuse  in- 
testinal discharges.  An  excess  is  seen  in  some  cases  of  phthisis,  of 
organic  brain  disease,  of  diabetes,  of  ostitis,  and  of  tumors  of  bone, 
also  in  chyluria.  The  calcium  elimination  (as  well  as  absorption)  is 
normal  in  both  rachitis  and  osteomalacia. 

Urea. — The  amount  of  urea  normally  excreted  varies  from  twenty 
to  forty-five  grammes  daily.  The  formation  and  elimination  are  in- 
creased in  a  rich  albuminous  diet ;  in  fever ;  in  bacterial  or  leucomaine 
intoxication ;  in  conditions  of  tissue-absorption  due  to  any  cause,  as  in 
the  severe  anaemias,  in  scorbutus,  diabetes,  and  chronic  constipation ; 
during  the  absorption  of  exudates  or  transudates ;  by  hot  or  cold 
baths ;  by  many  drugs,  as  chloroform,  caffeine,  morphine,  and  the 
salicylates ;  in  poisoning  from  arsenic,  antimony,  phosphorus,  and 
carbon  dioxide  ;  and  in  cases  of  severe  dyspnoea.  The  elimination  is 
decreased  in  a  vegetable  diet ;  in  starvation  and  malnutrition  ;  in  nearly 
all  the  acute  and  chronic  hepatic  diseases,  especially  acute  yellow 
atrophy ;  and  in  nearly  all  cases  of  organic  renal  disease,  with  the 
exception  of  primary  interstitial  nephritis.  Of  drugs,  the  bromides 
especially  reduce  the  urea.  It  is  irregularly  increased  or  decreased  in 
various  functional  and  organic  nerve  diseases. 

The  quantitative  estimation  of  urea  can  be  approximately  ac- 
complished by  the  hypobromite  method  with  the  use  of  Doremus's 
apparatus.  A  much  more  accurate  but  more  difficult  determination 
is  to  make  a  total  nitrogen  estimation  by  the  Kehldahl  method. 
Crystals  of  urea  nitrate  may  be  prepared  for  microscopic  examina- 
tion by  the  addition  of  an  excess  of  nitric  acid  to  a  concentrated  alco- 
holic solution  of  urea,  made  by  adding  alcohol  to  urine  which  has  been 
evaporated  to  a  syrupy  consistence,  filtering,  and  again  evaporating. 

Uric  Acid. — The  daily  elimination  ranges  from  one-tenth  to  one 
gramme.  It  is  increased  after  an  albuminous  diet,  in  acute  fevers, 
in  all  conditions  associated  with  exudation,  in  leukaemia,  in  some 
dyspepsias,  in  phosphorus  poisoning,  and  in  some  nervous  diseases. 
The  salicylates,  pilocarpine,  alkaline  carbonates,  glycerin,  and  hot  baths 
stimulate  the  output  of  uric  acid.  The  elimination  is  decreased  in 
hunger,  in  some  cases  of  nephritis,  in  diabetes,  the  anaemias,  and  lead 
poisoning,  and  by  quinine,  atropine,  and  alcohol.     The  excretion  in 


340  OENITO-URINAKY   DISEASES   AND   SYPHILIS. 

lithaemia,  gout,  and  rheumatism  is  irregular,  and  variations  are  incon- 
stant both  during  and  between  attacks,  so  that  the  amount  is  not  an 
index  of  the  presence  or  severity  of  any  of  these  conditions.  Uric 
acid  should  be  estimated  by  the  Salkowski  silver  method. 

KREAtiNiN  is  eliminated  to  the  extent  of  one  gramme  daily,  except 
that  it  is  increased  in  all  conditions  of  rapid  tissue-disintegration,  as  in 
fevers,  suppuration,  and  gangrene,  we  have  no  knowledge  of  it  which 
has  a  clinical  application.  It  reduces  cupric  sulphate  in  alkaline  solu- 
tions, and  may  thus  give  rise  to  fallacy  in  the  test  for  sugar  by  Fehling's 
test,  since  it  holds  the  copper  suboxide  in  solution. 

The  compounds  known  as  the  xanthin  bases  exist  in  traces  in 
normal  urine.  They  are  increased  in  leukaemia  and  in  some  con- 
ditions of  auto-intoxication. 

The  many  compounds  of  the  aromatic  series  normal  in  urine  are, 
apart  from  the  diet,  due  to  bacterial  disintegration  of  proteids  either 
in  the  alimentary  tract  or  in  the  tissues.  They  circulate  partly  as 
oxyacids  and  partly  as  ether-sulphates,  under  which  heading  patho- 
logical alterations  have  been  included. 

Closely  allied  to  the  xanthin  bases  and  the  aromatic  series  are  the 
ptomaines  and  toxins,  of  which  normal  urine  contains  a  trace.  They 
are  increased  in  many  conditions,  and  are  to  be  viewed  as  elimina- 
tions of  poisons  absorbed  from  the  ahmentary  tract  or  from  diseased 
areas  formed  in  the  body  by  the  chemical  actions  of  bacteria  or  by 
an  altered  metabolism.  The  clinical  examination  of  these  substances 
has  not  yet  been  formulated. 

Oxalic  Acid. — Normal  urine  contains  a  trace  of  ammonium  ox- 
alate, 0.05  gramme.  Although  the  oxalates  in  the  diet  are  partly 
absorbed  and  partly  eliminated,  the  normal  oxalic  acid  in  the  urine  is 
not  derived  from  the  diet,  but  is  a  product  of  metabolism.  The  amount 
is  strikingly  increased  in  diabetes,  in  jaundice,  and  in  many  cases  of 
chronic  gastritis  and  enteritis ;  to  a  less  degree  in  the  infectious  dis- 
eases and  in  functional  and  organic  nervous  diseases.  It  is  also  cer- 
tain that  oxalic  acid  may  be  formed  in  the  bladder  in  certain  cases 
of  cystitis. 

There  is  an  obscure  condition  known  as  essential  oxaluria  or  the 
oxalic  diathesis,  in  which  the  elimination  of  oxalic  acid  is  markedly, 
though  irregularly,  increased.  In  these  cases  of  oxaluria  there  is 
an  especial  tendency  to  the  formation  of  calculus.  Though  essential 
oxaluria  has  been  shown  to  be  connected  with  disturbances  of  either 
the  nitrogenous  or  the  carbohydrate  metabolism,  there  are  no  condi- 
tions in  the  urine  to  indicate  in  an  individual  case  in  which  direction 
the  disturbance  lies.     The  number  of  crystals  of  calcium  oxalate  is 


EXAMINATION   OF   THE    UEINE.  341 

not  always  proportional  to  the  quantity  of  oxalic  acid  in  the  urine, 
for  which  reason  quantitative  tests  are  often  desirable.  These  may 
be  accomplished  by  the  modified  method  of  Neubauer. 

Urobilin. — A  trace  of  urobilin  is  a  .normal  product  of  the  urine. 
In  conditions  of  pathological  urobilinuria  the  urine  is  brown  in  color, — 
light  or  dark  according  to  the  amount  of  urobilin.  It  is  moderately 
increased  in  the  infectious  fevers,  in  most  cases  of  hepatic  disease,  in 
the  essential  anaemias  and  other  blood  dyscrasias,  after  prolonged  ether 
or  chloroform  narcosis,  after  the  use  of  antifebrin  or  antipyrin,  and 
in  chronic  lead  poisoning.  An  excess  is  constant  following  internal 
hemorrhage.  It  is  best  detected  with  the  spectroscope ;  in  alkaline 
urine  it  has  absorption  bands  at  F ;  chemically  it  may  be  tested  by 
extraction  from  the  urine  with  chloroform,  to  which  Lugol's  solution 
and  potassium  hydrate  are  then  added,  when  a  green  fluorescence  is 
produced,  which  is  intense  according  to  the  amount  of  urobilin. 

Hj:matoporphyrin  is  likewise  present  in  normal  urine  as  the  faint- 
est trace.  It  is  greatly  increased  after  internal  or  intestinal  hemor- 
rhage, in  some  acute  febrile  processes,  and  especially  following  pro- 
longed use  of  sulphonal,  trional,  and  tetronal.  It  is  recognized  by  its 
absorption  bands  :  two  faint  bands  at  C-D  and  D-E,  two  heavy  bands 
at  D  and  b-F.     It  colors  the  urine  pink  or  red. 

Acetone,— A  trace  is  present  in  normal  urine,  rarely,  however, 
above  0.1  gramme.  It  is  in  excess  in  many  conditions.  Fever  per  se 
can  produce  it ;  it  is  constant  in  the  infectious  diseases,  and  in  some 
cases  of  gastro-intestinal  disturbances,  especially  gastric  dilatation.  It 
is  also  seen  in  inanition  and  marasmus,  in  the  malignant  cachexias,  in 
extreme  primary  or  secondary  anasmia,  and  after  chloroform  narcosis. 
There  is  often  a  striking  excess  in  diabetes. 

It  is  probable  that  it  occurs  as  a  result  of  disturbed  nitrogenous 
metabolism,  and  it  is  seen  typically  in  conditions  associated  with  rapid 
tissue-disintegration,  as  internal  gangrene.  There  are  rare  cases  of 
idiopathic  acetonuria,  and  it  can  be  produced  by  an  exclusive  meat  diet. 

To  determine  its  presence  a  few  drops  of  a  fresh  ten  per  cent, 
solution  of  sodium  nitro-prusside  should  be  added  to  the  suspected 
urine,  followed  by  a  few  drops  of  sodium  hydrate  (the  urine  must  be 
distinctly  alkaline),  when  a  red  color  will  be  produced,  which  is  turned 
to  purple  by  acetic  acid. 

ABNORMAL   SUBSTANCES   IX   THE   URINE. 

The  only  proteid  normal  in  urine  is  a  trace  of  nucleo-albumen, 
which  is  derived  from  the  epithelium.  The  proteids  which  may  ap- 
pear pathologically  in  greater  or  less   amount  are  serum-albumen, 


342  GENITO-UlimAEY   DISEASES   AND   SYPHILIS. 

globulin,  the  albumoses,  peptone,  fibrinogen  or  fibrin-globulin,  and 
nucleo-alburaen. 

Serum- Albumen. — This  proteid  is  not  present  in  the  urine  of 
healthy  adults  living  under  the  best  conditions  of  life,  but  traces  have 
been  found  in  a  notable  proportion  of  those  whose  diet,  hygiene,  and 
conditions  are  poor.  It  is  generally  found  in  the  urine  of  the  new- 
born, and  often  in  that  of  the  adolescent,  Avithout  signs  or  symptoms 
of  any  disease.  In  otherwise  healthy  adults  a  trace  may  follow  slight 
circulatory  or  digestive  disturbances,  excesses  in  exercise,  or  immod- 
erate indulgence  in  meats  without  symptoms  of  malassimilation,  or 
may  appear  in  he  course  of  various  nervous  diseases.  Nevertheless, 
albuminuria  should  always  arouse  suspicion,  and  a  diligent  search 
should  be  made  for  its  cause. 

The  amount  of  albumen  which  may  appear  in  the  urine  varies 
from  a  trace  to  three  per  cent,  by  weight ;  what  is  clinically  termed  a 
moderate  amount  of  albumen  corresponds  to  from  one-half  to  one 
per  cent. ;  a  pronounced  amount  is  over  one  per  cent.  Since  in  the 
worst  cases  the  amount  eliminated  amounts  to  no  more  than  fifteen 
grammes  daily,  it  is  obvious  that  the  actual  loss  of  the  albumen  itself 
is  of  very  trifling  consequence  to  the  organism. 

Renal  albuminuria  occurs  in  all  forms  of  nephritis.  The  albun;on 
is  present  in  large  quantities  in  acute  and  chronic  parenchymatcu? 
nephritis,  in  small  quantities  in  amyloid  and  chronic  interstitial 
nephritis.  Indeed,  while  in  parenchymatous  nephritis  albumen  is,  as 
a  rule,  constant  and  at  times  present  in  such  quantity  that  the  urine 
solidifies  on  boiling,  in  interstitial  nephritis  it  may  be  absent  for  days 
at  a  time. 

In  pyelonephrosis  and  hydronephrosis  the  amount,  while  usually 
small,  is  variable  and  liable  to  sudden  fluctuations. 

Albuminuria  occurs  in  all  febrile  conditions  and  in  the  infectious 
diseases,  due  partly  to  circulatory  disturbances,  partly  to  the  altered 
blood,  and  partly  to  the  action  of  fever  and  toxins  upon  the  renal 
structure.  It  is  seen  in  all  acute  and  in  many  chronic  diseases  of 
the  alimentary  tract ;  here  again  it  is  toxic  in  nature.  It  occurs  in 
general  or  local  circulatory  disturbance,  due  in  the  main  to  conse- 
quent disturbance  of  secretion,  although  in  chronic  heart  disease 
structural  renal  change  is  eventually  added.  Any  form  of  acute  or 
chronic  heart  disease  may  show  albuminuria. 

The  most  common  local  conditions  which  disturb  the  renal  cir- 
culation are  pressure  upon  the  renal  vessels,  as  by  a  tumor,  and  dis- 
placement of  a  floating  kidney.  Renal  isch^emia,  although  much 
rarer  than  arterial  hypersemia  or  venous  stasis,  is  not  uncommonly 


EXAMINATION   OF   THE   URINE.  343 

the  cause  of  albuminuria,  as  in  cholera  and  severe  diarrhoeas.  The 
albuminuria  of  pregnancy  is  likewise  to  be  classed  as  a  circulatory 
disturbance,  although  intoxication  plays  a  rdle. 

Transfusion  of  the  serum  of  a  chfferent  species  is  always  followed 
by  albuminuria,  which  occurs  in  some  cases  of  transfusion  of  hmnan 
serum  or  of  saline  solutions. 

In  the  blood  dyscrasise,  severe  primary  or  secondary  anaemia, 
leukaemia,  scurvy,  purpura,  and  the  cachexia  of  malignant  disease  or 
of  chronic  syphilis  or  tuberculosis,  there  is  generally  a  small  amount 
of  albumen  present  in  the  urine,  due  to  slight  structural  changes  in 
the  kidney,  the  result  of  malnutrition. 

There  is  frequently  a  transient  albuminuria  following  the  convul- 
sions of  epilepsy  or  of  organic  nervous  disease,  not  seen,  as  a  rule, 
after  hysterical  convulsions.  A  similar  albuminuria  is  due  to  vaso- 
motor disturbances,  as  in  the  so-called  cyclical  or  paroxysmal  albu- 
minuria, which  is  often  reflex  to  a  cutaneous  chilling,  as  after  a  cold 
bath.  Obviously  blood  or  lymph  exuding  from  the  kidney-substance 
causes  albuminuria,  and  it  is  thus  seen  in  tuberculosis,  malignant  dis- 
ease, suppuration,  or  stone  in  the  substance  of  the  kidney. 

Many  drugs  and  poisons  cause  albuminuria  by  arterial  hyperaemia 
and  irritation  of  the  epithehum.  The  most  common  of  these  are 
chloroform,  ether,  alcohol,  carbolic  acid,  salicylic  acid  and  its  salts, 
corrosive  mercuric  chloride,  arsenic,  iodoform,  phosphorus,  lead,  can- 
tharides,  turpentine,  and  juniper. 

In  jaundice  and  haemoglobinuria  albumen  is  often  present.  Ex- 
ceptionally it  can  be  produced  by  excessive  hyperacidity  of  the  urine, 
but  uric  acid  per  se  does  not  produce  it. 

In  all  these  instances  of  albuminuria  globuhn  is  present :  a  strict 
serum-albuminuria  is  an  extremely  rare  condition. 

Subrenal  or  contingent  albuminuria  is  most  important  from  the 
surgical  aspect.  Inflammation  of  the  mucous  membrane  of  the  pelvis 
of  the  kidney,  of  the  ureter,  of  the  bladder,  or  of  the  urethra,  hemor- 
rhage from  any  of  these  areas,  and  malignant  or  tubercular  disease, 
all  produce  albumen  in  the  urine,  in  small  but  variable  amounts.  In 
chyluria,  or  where  lymph  or  pus  is  emptied  into  the  urinary  tract, 
albumen  is  likewise  present.  A  calculus  in  the  pelvis,  ureter,  or 
bladder  usually  causes  albuminuria,  but  here  the  phenomenon  is  likely 
to  be  irregular.  Inflammation  or  other  disease  of  the  seminal  vesicles 
causes  albuminuria  occasionally,  and  it  is  of  course  seen  in  sperma- 
torrhoea. 

Renal  albuminuria  must  be  distinguished  from  subrenal  albu- 
minuria by  a  careful  study  of  the  sediment  for  evidences  of  nephritis, 


344  GENITO-ITRINAEY   DISEASES   AND   SYPHILIS. 

and  of  the  whole  urine  for  evidences  of  the  special  causes  of  sub- 
renal albuminuria.     (For  tests  for  Albumen,  see  page  361  et  seq.) 

Globulin  generally  accompanies  serum-albumen,  in  the  propor- 
tion of  1  to  8  :  15.  In  the  albuminuria  of  amyloid  kidney,  however,, 
and  in  haematuria  and  pyuria,  the  ratio  of  globulin  to  serum-albumen 
is  much  higher, — 1  to  1.5  :  4  ;  thus  constituting  an  important  element 
in  differential  diagnosis. 

Albumoses  rarely  appear  in  an  ordinary  case  of  albuminuria. 
They  are,  however,  seen  in  the  urine  of  some  cases  of  eruptive  fevers,. 
in  osteomalacia,  in  many  cases  of  bone-tumors,  and  in  some  cases  of 
nephritis  and  leukaemia. 

Very  important  is  pyogenic  albumosuria  (formerly  called  pyogenic 
peptonuria  :  it  has  been  shown,  however,  that  the-  proteids  are  gener- 
ally albumoses  and  not  true  peptones).  It  is  seen  in  conditions  of  in- 
ternal suppuration, — meningitis,  appendicitis,  purulent  inflammations- 
of  the  great  serous  membranes,  pneumonia,  and  gangrene,  also  in 
tuberculosis  and  chronic  phosphorous  poisoning. 

Peptonuria. — True  peptone  is  rarely  present ;  the  peptonuria  has 
been  shown  to  be  caused  by  albumoses  which  are  not  precipitated 
by  a  neutral  saturation  with  ammonium  sulphate,  the  test  employed. 
True  peptone  survives  a  triple  precipitation  (neutral,  acid,  alkaline) 
with  ammonium  sulphate,  and  has  been  found  so  exceptionally  that 
it  possesses  no  clinical  value. 

FiBRiNURiA. — The  fibrin  may  or  may  not  be  in  actual  coagulation 
when  the  urine  is  voided.  It  is  seen  in  some  cases  of  profuse  haema- 
turia, in  chyluria,  and  more  constantly  where  there  is  a  coagulation- 
necrosis,  as  in  membranous  pyelitis  or  in  tuberculosis  of  the  pelvis,, 
ureter,  or  bladder. 

Fibrin  threads  should  be  collected  on  a  filter-paper,  washed,  dis- 
solved in  hot  one-half  per  cent,  hydrochloric  acid  solution,  and  the 
solution  then  treated  for  albumen.  Threads  of  similar  appearance 
have  been  described  in  the  urine  as  the  result  of  the  action  of  micro- 
organisms ;  these  can  be  differentiated  from  true  fibrin  by  Weigert's- 
fibrin-stain  (a  modified  Gram's  stain). 

Nucleo-Albumen  (mucin). — A  trace  of  this  proteid  exists  in  normal 
urine,  but  whether  preformed  or  not  is  yet  to  be  determined.  A  nor- 
mal amount  never  affects  the  appearance  of  the  urine.  A  pathological 
quantity  is  visible  in  the  urine  as  a  cloud,  which  settles  and  draws  with 
it  the  sediment.  If  the  urine  be  diluted  so  that  the  saline  concentra- 
tion is  much  diminished,  the  nucleo-albumen  will  be  precipitated  by 
the  addition  of  acetic  acid. 

A  pathological  increase  is  seen  in  the  blood  dyscrasise,  jaundice. 


EXAMINATION    OF    THE    URINE.  345 

and  venous  renal  stasis,  and  in  many  local  conditions,  notably  pyelitis, 
cystitis,  cowperitis,  prostatitis  (prostatorrlioea),  inflammation  of  the 
seminal  vesicles,  and  calculus  anywhere  in  the  urinary  tract. 

True  mucin  (a  glycoproteid)  is  very  rarely  present  in  either  nor- 
mal or  pathological  urine.  Mucin  reduces  cupric  sulphate  in  alkaline 
solution,  while  nucleo-albumen,  containing  an  atom  of  phosphorus  in 
its  molecule,  is  distinguished  by  the  reactions  of  that  element. 

Haematuria. — A  small  amount  of  blood  need  not  color  the  urine  ; 
large  amounts  produce  a  pale  pink  to  a  deep  red  color.  Accidental 
haematuria  is  that  due  to  traumatism  of  any  part  of  the  urinary  tract 
or  to  the  presence  of  foreign  bodies  in  the  urethra  or  bladder. 

Blood  may  appear  in  the  urine  in  any  form  of  nephritis,  from 
febrile  or  infectious  hypereemia  to  the  last  stage  of  degenerative  ne- 
phrosis ;  it  is  most  frequently  seen  in  congestion,  acute  parenchyma- 
tous nephritis,  and  the  acute  exacerbations  of  the  chronic  disease,  and 
regularly  follows  renal  infarcts  or  thrombosis.  Blood  is  irregularly 
present  in  the  renal  disturbances  secondary  to  heart  disease. 

In  tuberculosis  and  malignant  disease  of  the  kidney,  or  of  any 
part  of  the  urinary  tract,  haematuria  is  regularly  seen,  although  here 
the  phenomenon  may  vary  much  as  to  quantity  and  periods.  The 
rare  echinococcus  cysts  of  the  kidney  hkewise  cause  it. 

In  the  blood  dyscrasiee  and  in  haemophilia  there  may  be  inter- 
mittent attacks  of  haematuria ;  and  intermittence  is  the  rule  in  cystic 
kidneys  and  hydronephrosis.  Renal  calculus  generally  causes  a  mild 
but  constant  haematuria,  though  in  some  instances  it  may  be  profuse. 
In  the  rare  internal  traumatisms  of  the  kidney,  as  in  torsion  of  a 
floating  kidney,  haematuria  follows  the  accident. 

As  a  rule,  it  may  be  said  that,  with  the  exception  of  the  bleeding 
from  a  ruptured  vessel  or  from  tumor  or  granuloma  of  the  kidney, 
renal  haematuria  never  presents  clots.  Subrenal  hgematuria  is  very 
common.  The  same  causes  that  apply  to  the  kidney  hold  true  for 
the  pelvis. 

Stone  in  the  bladder  is  a  common  cause  of  intermittent  haematuria, 
but  the  character  is  not  constant.  The  tumors  of  the  bladder  like- 
wise present  intermittent  haematuria  of  variable  intensity,  though 
the  malignant  tumors  generally  bleed  more  freely  than  papilloma. 
Inflammation  of  the  mucous  membrane  of  any  part  of  the  urinary 
tract,  and  extreme  congestion  or  rupture  of  dilated  veins,  may  cause 
haematuria. 

In  the  tropics  parasites,  as  the  distoma,  frequently  cause  a  severe 
hgematuria. 

The  presence  of  blood  in  the  urine  should  be  considered  micro- 


346  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

scopically,  spectroscopically,  and  chemically.  The  microscopical  ap- 
pearance will  be  considered  under  the  heading  of  sediments. 

Blood  in  the  urine  presents  the  absorption  bands  of  oxyheemo- 
globin,  between  D  and  E,  which,  after  the  addition  of  a  little  am- 
monia and  ammonium  sulphate,  are  merged  into  the  broad  band 
of  reduced  heemoglobin  between  D  and  E,  or  of  methsemoglobin  be- 
tween C  and  D,  at  D,  at  E,  and  at  F. 

A  delicate  chemical  test  is  that  of  Struve :  Add  to  urine  a  little 
potassium  hydrate ;  then  add  acetic  acid  and  tannic  acid  until  the 
urine  is  again  acid ;  if  blood  be  present,  a  dark  precipitate  will  form ; 
this  dried  precipitate  when  treated  with  ammonium  chloride  and 
glacial  acetic  acid  will  form  the  heemin  crystals. 

By  a  careful  count  of  the  red  and  white  corpuscles  following  the 
addition  to  the  urine  of  a  little  methyl-violet  (which  tinges  the  white 
cehs),  the  simultaneous  presence  of  pyuria  can  be  proved  or  ex- 
cluded. 

With  every  heematuria  there  is  obviously  albuminuria.  Whether 
the  albuminuria  be  entirely  dependent  upon  the  haematuria  is  a  mat- 
ter often  difficult  to  decide.  The  ratio  of  serum-albumen  to  globulin 
promises  practical  assistance  in  deciding  this  matter.  In  a  renal  al- 
buminuria this  varies  from  9  to  15  :  1.  The  ratio  in  the  blood  varies 
from  IJ  to  3:1.  Obviously,  when  hsematuria  is  the  cause  of  the 
albuminuria  the  ratio  will  approach  that  of  the  blood.  For  instance, 
amyloid  kidney  being  excluded,  if  in  a  given  case  the  ratio  of  the 
serum-albumen  to  the  globulin  be  9  to  15  :  1,  this  will  show  the 
existence  of  albuminuria  independent  of  hsematuria.  If,  on  the  other 
hand,  the  ratio  in  a  given  case  be  3  :  1,  it  is  likely  that  the  albumi- 
nuria is  entirely  dependent  on  the  hgematuria.  It  may  be  stated, 
then,  that  the  more  nearly  the  ratio  in  any  given  case  approaches  the 
blood  ratio  or  the  albuminuria  ratio,  the  more  positive  the  suggestion ; 
naturally,  there  will  be  results  which  fall  midway,  and  in  these  cases 
the  test  is  negative. 

Hsemoglobinuria  is  the  presence  of  hasmoglobin  in  solution  in 
the  urine  independent  of  the  blood-corpuscles.  It  generally  accom- 
panies hsemoglobinaemia. 

Hsemoglobinuria  may  coexist  with  haematuria.  It  is  seen  in  some 
cases  of  severe  infectious  disease :  in  burns  of  wide-spread  area :  in 
some  cases  of  pyaemia,  jaundice,  scurvy,  and  fat  emboli :  and  in  severe 
poisoning  by  coal-tar  phenol  compounds,  as  carbolic  acid  and  naphtol ; 
by  pyrogallic  acid,  the  chlorates,  iodine,  arsenic,  and  glycerin ;  by  in- 
organic acids,  as  hydrochloric,  sulphuric,  and  phosphoric ;  and  by 
organic  poisons  sometimes  present  iti  shell-fish.    Transfusions  of  blood 


EXAMINATION    OF    THE    UKINE.  347 

or  of  serum,  especially  from  a  different  species,  can  produce  it.  It  is 
the  main  sign  of  the  obscure  condition  known  as  paroxysmal  hsemo- 
globinuria.  No  cases  of  the  parasitic  endemic  haemoglobinuria  seen 
in  animals  have  been  observed  in  man. 

The  urine  contains,  in  addition  to  hsemoglobin,  albumen,  gener- 
ally hyaline  casts,  and  bilirubin  or  biliverdin,  and  quite  often  there  is 
a  sediment  of  amorphous  or  crystalline  hsemin,  while  in  some  cases 
crystals  of  calcium  oxalate  are  present  in  large  quantities.  The  urine 
may  be  alkaline. 

The  diagnosis  of  haemoglobin  is  made  by  establishing  the  presence 
of  haemoglobin  without  red  corpuscles  or  entirely  out  of  proportion  to 
the  number  of  red  corpuscles. 

Carbohydrates. — Carbohydrates  which  appear  in  the  urine  are 
grape-sugar,  levulose,  inosite,  maltose,  the  pentoses,  and  lactose. 

The  ordinary  glycosuria  concerns  the  glucose  group.  A  trace  of 
sugar  probably  exists  in  normal  urine,  but  this  is  never  sufficient  to 
respond  to  clinical  tests. 

There  is  often  a  transitory  glycosuria  in  cases  of  acute  infectious 
disease ;  in  many  acute  and  chronic  heart,  lung,  and  especially  liver 
diseases  ;  in  lithsemia  and  gout,  where  it  is  frequent ;  in  syphilis,  and 
in  exophthalmic  goitre.  This  phenomenon  is  irregularly  seen  in  the 
chronic  derangements  of  the  digestive  tract.  It  is  frequent  in  nervous 
diseases  (apart  from  the  relation  of  the  medulla  to  diabetes)  and  in  the 
traumatic  neuroses,  particularly  of  the  abdominal  sympathetic  system. 

Sugar  may  appear  in  the  urine  of  any  form  of  nephritis,  but  it  is 
most  often  seen  in  the  interstitial  nephritis  of  gouty  persons.  It  is 
probable  that  an  exclusive  starch  diet  or  a  surfeit  of  sugar  can  pro- 
duce a  glycosuria  in  the  normal  subject,  but  it  will  do  so  more  con- 
stantly in  nervous  overworked  individuals  or  in  those  subject  to 
digestive  derangements.  There  is  a  rare  glycosuria  of  adolescence, 
analogous  to  the  albuminuria.  It  occurs  in  phosphorus,  amyl  nitrite, 
turpentine,  chloral,  and  carbon  monoxide  poisoning,  and  in  acute  or 
chronic  morphine  poisoning.  These  drugs  may  cause  the  appearance 
of  reducing  agents,  as  glycuronic  acid,  which  may  be  mistaken  for  sugar. 
Sugar  is  present  in  the  urine  of  pregnancy  and  the  puerperium  almost 
as  frequently  as  albumen.  It  is,  fmally,  most  important  as  the  chief 
sign  of  the  distorted  metabolism  of  essential  diabetes. 

Experimentally  diabetes  can  be  caused  by  injury  to  the  medulla 
oblongata  or  by  extirpation  of  the  pancreas,  and  a  renal  glycosuria 
can  be  produced  by  the  administration  of  phloridzin  (For  Qualitative 
and  Quantitative  Tests,  see  pages  364,  365.) 

The  amount  of  sugar  in  the  urine  may  be  as  high  as  two  and  one- 


348  GENITO-UKINARY    DISEASES   AND   SYPHILIS. 

fifth  pounds  per  diem,  but  one-fourth  that  amount  is  a  heavy  glyco- 
suria. The  specific  gravity  of  urine  usually  bears  a  rough  relation  to 
the  amount  of  sugar  it  contains,  but  exceptions  to  this  are  not  un- 
common. 

Large  amounts  of  sugar  are  practically  seen  only  in  true  diabetes ; 
in  the  other  varieties  of  glycosuria  the  amount  rarely  reaches  two  per 
cent. 

Of  the  other  forms  of  sugar,  none  have  any  clinical  significance  in 
their  relations  to  the  urine,  except  lactose,  which  not  uncommonly  is 
present  in  the  urine  of  the  nursing  mother. 

Choluria. — In  jaundice  the  biliary  coloring  matters  are  always 
present  in  the  urine,  the  salts  of  the  biliary  acids  seldom.  In  fresh 
icteric  urine  the  pigment  is  bilirubin  in  alkaline  combinations  ;  on 
standing  the  bihrubin  is  oxidized  to  biliverdin,  or  to  lower  compounds, 
— changes  also  which  occur  in  the  bladder  in  cases  of  cystitis  in  a 
jaundiced  subject. 

The  urine  has  a  yellow-greenish  color.  Allowed  to  come  in  con- 
tact with  old  fuming  nitric  acid  containing  nitrous  acid,  a  green  color 
forms  at  the  point  of  contact  (Gmelin's  test) :  this  reaction  can  be  made 
more  striking  if  the  acid  be  dropped  upon  a  filter-paper  through  which 
the  urine  has  been  filtered.  The  salts  of  the  bile  acids  cannot  be 
demonstrated  by  clinical  methods. 

The  urine  may  contain  bile  in  any  acute  or  chronic  disease  of  the 
liver  or  the  bile-tracts ;  it  is  especially  marked  in  obstruction  of  the 
common  duct.  It  is  generally  seen  following  attacks  of  hepatic  colic, 
even  though  the  mucous  membranes  and  the  skin  show  no  trace  of 
jaundice ;  it  likewise  follows  operations  upon  the  liver  or  the  bile- 
tracts,  and  phosphorus  poisoning.  It  is  very  doubtful  whether  choluria. 
dependent  on  heematogenous  icterus  exists. 

Cholesterin  is  not  found  in  jaundiced  urine.  It  may  be  seen  in 
cases  of  severe  cystitis,  in  tuberculous  nephritis,  in  chyluria,  and  fol- 
lowing prolonged  ingestion  of  potassium  bromide. 

Cystinuria. — Cystin  in  the  urine  is  generally  accompanied  by  cada- 
verin  and  putrescin.  It  has  been  recorded  as  a  family  disease.  It  is 
seen  in  acute  yellow  atrophy  of  the  liver,  occasionally  during  the 
course  of  infectious  diseases,  and  in  the  peculiar  condition  known  as 
idiopathic  cystinuria,  some  cases  of  which  have  been  shown  to  be  due 
to  a  specific  form  of  albumen  putrefaction  within  the  alimentary  tract. 
It  is  best  diagnosed  by  the  sediment,  and,  as  it  may  be  insoluble,  a 
trace  appears  as  a  sediment. 

Melanin. — A  trace  of  melanin  or  melanogen  appears  in  the  urine 
in  most  cases  of  melano-sarcoma,  and  also,  though  less  often,  in  car- 


EXAMINATION    OF    THE    UEINE.  349 

■cinomatous  processes  ;  it  has  been  seen  in  marasmus.  The  pigment 
is  generally  in  solution,  but  there  may  be  a  sediment  of  blackish 
granules.  The  urine  is  dark,  but  the  color  may  develop  only  after 
exposure  to  the  air. 

DiACETic  ACID  is  secu  in  the  urine  under  conditions  similar  to  those 
in  which  acetone  appears,  and  it  is  generally  accompanied  by  the  lat- 
ter. It  occurs  in  high  fever,  in  infectious  processes,  in  metabolic  auto- 
intoxications, and  in  diabetes.  It  gives  a  Bordeaux-red  reaction  v^^ith 
ferric  chloride,  but  there  are  many  fallacies  inseparable  from  the  test, 
and  for  a  reliable  estimation  a  distillation  is  necessary. 

Lipuria. — Fatty  acids  are  normal  in  the  urine,  but  fat  probably  is 
not.  The  fatty  acids  are  increased  in  fever  and  in  acute  and  chronic 
hepatic  diseases,  and  are  present  in  great  excess  in  diabetes  and  in 
the  ammoniacal  urine  of  cystitis. 

The  term  lipuria  is  generally  limited  to  the  presence  of  free  fat, 
not  fat  in  degenerated  renal  epithelium,  etc.  A  large  quantity  of  fat 
Avill  cause  a  whitish  cloudiness  in  the  urine,  but  this  condition  is  rare. 
More  often  the  fat  appears  as  a  scum  floating  upon  the  urine,  but 
generally  it  must  be  searched  for  with  the  microscope ;  with  this 
Instrument  the  fat-globules  are  easily  recognized.  If  the  urine  be 
extracted  with  ether  and  this  evaporated  upon  a  filter-paper,  a  fat- 
stain  will  be  left  upon  the  paper  which  will  blacken  with  osmic  acid. 

Fat  may  appear  in  the  urine  in  the  last  stages  of  nephritis  and  in 
pyelonephritis  ;  in  acute  and  chronic  hepatic  and  pancreatic  disease  ; 
in  pregnancy ;  in  the  cachexia  of  phthisis  and  other  wasting  diseases  ; 
in  diabetes,  and  in  chronic  phosphorus  poisoning.  It  is  more  con- 
stant in  long-standing  suppuration,  especially  of  the  bones  and  joints, 
in  malignant  tumors  of  these  structures,  and  in  pyaemia  and  gangrene. 

Lipuria  is  constant  with  chyluria,  and  is  found  when  a  cyst  or  an 
abscess  ruptures  into  the  urinary  tract ;  it  is  likewise  generally  found 
after  fractures  or  operations  upon  bones. 

Ohyluria  is  thus  named  because  of  the  milk-white  appearance 
of  the  urine.  The  urine  in  this  condition  contains  albumen,  globulin, 
fibrinogen  and  fibrin-globulin,  blood,  fat,  tissue-cells,  cholesterin,  and 
lecithin.  On  standing,  more  or  less  fibrin  always  forms,  and  often 
•complete  coagulation  occurs.  Generally  the  urine  contains  these  sub- 
stances only  at  some  time  of  the  day,  while  at  other  times  it  is  clear. 

The  cause  is  almost  always  the  filaria  sanguinis  hominis,  but  how 
the  parasite  brings  about  this  phenomenon  is  not  understood.  It  has 
been  generally  supposed  that  chyluria  is  caused  by  an  abnormal 
communication  between  the  lymph-channels  and  the  urinary  tract, 
the  lymph  thus  mingling  directly  with  the  urine.     The  constituents 


350  GENITO-UKINAKY    DISEASES    AND    SYPHILIS. 

of  the  fluid,  however,  are  not  the  same  as  those  of  lymph :  there 
is  no  sugar  in  chyluria,  while  sugar  is  abundant  in  the  lymph,  and 
furthermore'  the  amount  of  fat  present  in  chyluria  far  exceeds  the 
quantity  contained  in  lymph. 

Bacteriuria  implies  the  presence  of  bacteria  in  the  urine  with 
pus  either  absent  or  present  in  small  quantity.  It  is  usually  the  ex- 
pression of  a  renal  eliminative  process,  but  may  represent  the  earliest 
or  the  terminal  phenomenon  of  local  inflammation.  Of  one  hundred 
and  thirty-two  cases  of  bacteriuria  quoted  by  Ellis,  the  colon  bacillus 
was  the  causative  factor  in  seventy-five.  In  twenty  to  thirty  per  cent, 
of  typhoid  fever  the  typhoid  bacilli  are  found  in  the  urine  after  the 
second  week  and  may  persist  for  years.  The  tubercle  bacilli,  staphy- 
lococci and  streptococci,  bacillus  proteus,  and  subtilis  are  other  bac- 
teria which  are  occasionally  found. 

Bacteriuria  rarely  produces  the  symptoms  of  inflammation  in  a 
previously  healthy  well-drained  urinary  tract,  though  hyperEemia  and 
excessive  mucous  secretion  are  common  expressions  of  the  irritating 
effects  of  the  abnormal  urine. 

Symptoms. — The  cardinal  symptom  is  the  discovery  of  bacteria 
in  pus-free  urine.  The  urine  when  voided  is  often  cloudy  and  offen- 
sive. The  cloudiness  is  not  removed  by  acidulation,  filtration,  or 
sedimentation.  There  is  positive  albuminuria  wdien  the  micro-organ- 
isms have  been  eliminated  through  the  kidneys.  The  urine  is  acid 
except  when  it  contains  the  staphylococcus  or  the  bacillus  proteus 
vulgaris. 

The  local  symptoms  are  those  of  slight  irritation,  which  may 
progress  to  those  of  true  inflammation. 

Treatment  has  for  its  end  the  removal  of  the  cause.  Since  consti- 
pation is  a  usual  cause  for  colonic  bacteriuria,  rectal  lavage  is  particu- 
larly serviceable  w^hen  this  organism  (the  colon  bacillus)  is  found.  In 
general,  urinary  antiseptics  should  be  given  in  small  doses  and  instru- 
mentation should  be  avoided. 

Pneumaturia  usually  denotes  a  communication  between  the 
bowel  and  the  bladder ;  it  also  occurs  from  the  intravesical  fermen- 
tation of  diabetic  urine,  and  is  reported  as  having  been  caused  by  the 
bacillus  aerogenes  capsulatus. 

In  emptying  the  bladder  by  catheter,  air  is  sometimes  introduced 
into  the  bladder  by  the  manipulations  of  the  nurse  in  pressing  firmly 
upon  the  hypogastric  region  to  expel  the  last  drops  of  urine.  When 
this  pressure  is  removed,  the  air  may  be  aspirated. 


EXAMINATION    OF    THE    UKINE.  35X 

THE   SEDIMENTS   IN  URINE. 

Normal  urine  may  be  entirely  free  from  sediment ;  it  often  con- 
tains urates.  To  preserve  urine  for  examination  of  the  sediment, 
chloroform  is  a  convenient  agent.  An  analysis  is  facilitated  by  cen- 
trifugation. 

Blood. — The  causes  have  already  been  given.  Upon  the  study 
of  the  sediment  often  depends  the  diagnosis  of  the  source  of  the 
hemorrhage,  and  whether  or  not  there  is  an  albuminuria  independent 
of  the  hsematuria. 

Since  inflammation  or  tumor  of  the  bladder-walls,  severe  and 
advanced  enough- to  cause  vesical  bleeding,  generally  renders  the 
urine  alkahne,  blood  in  acid  urine  points  to  the  ureter  or  kidney, 
while  blood  in  alkaline  urine  points  to  the  bladder.  To  this  rule 
there  are  many  exceptions,  since  there  is  not  infrecjuently  vesical 
hemorrhage  without  alkalinity  of  the  urine,  and  the  renal  lesions 
wrhich  cause  hemorrhage  may  coexist  with  or  arise  in  the  course  of 
chronic  cystitis. 

The  appearance  of  the  blood  in  the  urine  often  suggests  the  source. 
As  before  mentioned,  profuse  hemorrhage  with  clotting  rarely  comes 
from  above  the  bladder ;  when  it  is  renal,  worm-like  ureteral  casts 
may  be  found. 

If  the  red  corpuscles  are  much  altered,  deprived  of  their  haemo- 
globin (shadow-cells),  and  especially  if  they  present  fragmentation,  a 
renal  origin  is  strongly  suggested.  Crenation,  however,  is  largely  a 
physical  condition,  and  does  not  suggest  the  source. 

If  the  blood  comes  from  the  kidney,  hyaline  and  often  blood-casts 
can  generally  be  found  after  careful  centrifugation.  In  rare  cases 
pieces  of  tissue  will  suggest  the  seat  of  lesion. 

In  vesical  haematuria  more  of  the  lining  epithehal  cells  are  present 
than  when  the  blood  comes  from  the  ureter  or  the  pelvis ;  the  cells 
cannot  be  differentiated,  but  the  degree  of  desquamation  which  often 
occurs  in  cystitis  is  not  observed  in  ureteritis  or  pyelitis. 

To  determine  whether  pus  coexists  with  blood,  the  red  and  white 
corpuscles  should  be  counted  by  mixing  the  sediment  in  salt  solution 
colored  with  methyl-violet,  and  employing  the  ruled  slide  of  the 
Thoma-Zeiss  haemocytometer.  A  large  excess  of  white  corpuscles 
would  point  to  a  coexisting  pyuria,  which  might  serve  as  a  point  of 
diagnosis  between  renal  tuberculosis  and  nialignant  disease  or  other 
kidney  conditions. 

To  determine  in  a  doubtful  case  whether  an  albuminuria  is  de- 
pendent upon  or  simply  coexists  with  a  haematuria,  in  the  absence 


352  GENITO-ITEINAEY   DISEASES   AND    SYPHILIS. 

of  all  other  signs  of  renal  disease,  careful  computation  and  com- 
parison of  the  amount  of  blood  and  albumen  present  are  necessary. 
Goldberg  has  thus  formulated  a  method  of  settling  this  point.  The 
T3lood  is  evenly  mixed  into  the  mass  of  urine  and  the  cells  are  counted 
with  the  Thoma-Zeiss  hsemocytometer.  If  there  are  no  more  than 
three  thousand  cells  per  cubic  centimetre  and  the  urine  gives  an  albu- 
men reaction  with  nitric  acid,  the  albuminuria  is  not  dependent  on 
the  hsematuria,  as  that  amount  of  blood  will  give  no  such  reaction  for 
albumen.  If  the  number  of  red  blood-cells  per  cubic  millimetre  is  di- 
vided into  the  percentage  of  albumen  (as  determined  by  the  Esbach 
method),  any  figure  below  one-thirty-thousandth  means  that  the  albu- 
men is  due  solely  to  the  blood  ;  any  figure  over  one-thirty-thousandth 
indicates  an  independent  albuminuria.  For  example,  two  cases  may 
be  given : 

1.  In  a  given  specimen  of  bloody  urine  from  urethral  hemorrhage 
there  were  one  hundred  thousand  blood-cells  in  each  cubic  millimetre, 
and  the  cjuantity  of  albumen  was  one-third  per  cent.  The  propor- 
tion then  stands  100,000  cells  per  cubic  millimetre :  |^  of  1  per  cent, 
albumen  =  fotVott  •  hence  an  albuminuria  due  solely  to  the  blood. 

2.  In  the  urine  of  renal  tuberculosis,  the  number  of  cells,  the  per- 
centage of  albumen,  and  the  ratio  were  thus  expressed :  10,000  cells 
per  cubic  millimetre :  5  per  cent,  albumen  =  2V0  o"  5  therefore  there 
was  independent  albuminuria. 

Pus. — A  few  leucocytes  are  occasionally  seen  in  normal  urine, 
especially  of  women.  As  a  pathological  condition  it  is  a  frequent 
phenomenon. 

Small  amounts  of  pus  may  appear  in  the  urine  of  any  case  of 
nephritis,  but  only  in  septic  nephritis,  pyonephrosis,  and  tubercular 
and  malignant  kidneys  are  large  amounts  of  renal  pus  formed.  In 
cystic  kidneys  and  pyonephrosis  the  pyuria  is  often  intermittent,  and 
may  appear  in  large  quantity  in  a  sudden  attack  of  polyuria. 

In  pyelitis  and  urethritis  suppuration  may  be  free,  but  it  is  most 
profuse  in  cystitis,  particularly  in  the  tubercular  and  obstructive  forms 
of  the  disease.  A  sudden  discharge  of  pus  may  mean  the  rupture  of 
an  abscess  into  the  urinal  tract, — from  the  periurethral  glands,  the 
prostate  or  seminal  vesicles,  the  pericystic  region,  or  the  perirenal 
tissues. 

When  a  quantity  of  pus  precedes  the  stream  the  origin  is  obviously 
urethral ;  when  a  few  drops  follow  the  stream  the  origin  may  be  in 
the  prostate  gland,  the  seminal  vesicles,  or  the  bladder.  As  a  rule, 
pyuria  due  to  urethritis  clears  on  standing,  that  due  to  cystiLis  does  not. 

Pus  in  acid  urine  generally  conies  either  from  above  or  from  below 


Fig.  114. 

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EXAMINATION   OF    THE    UEINE.  353 

the  bladder,  since  the  urine  in  cystitis  is  usually  alkaline.  This  rule 
has  many  exceptions.  If  the  pus-cells  are  much  degenerated,  this  sug- 
gests a  high  origin  ;  renal  abscess  often  presents  tissue-fragments,  and 
hyaline  casts  are  often  present  in  renal  pyuria.  In  pyelitis  the  pus- 
cells  are  sometimes  grouped  about  large  cylindrical  plugs  which  come 
from  the  papillary  ducts.  The  pyuria  of  cystitis  is  accompanied  by 
a  large  number  of  the  lining  epithelial  cells,  more  numerous  than  in 
pyelitis.  The  ammonium  carbonate  in  strongly  alkaline  urine  may 
convert  pus  into  a  colloid  mass,  so  that  pus-cells  cannot  be  recognized. 

Pus  in  the  urine  forms  a  whitish  cloud,  often  stringy,  on  account 
of  the  increased  quantity  of  nucleo-albumen  present;  for  microscopic 
study  this  difficulty  may  be  obviated  by  the  addition  of  a  little  dilute 
acetic  acid  to  the  sediment.  The  pus  should  be  removed  upon  cover- 
glasses  and  fixed  by  passing  through  the  flame.  If  stained  with  the 
Ehrlich  triple  stain,  pus-cells  generally  present  neutrophilic  granula- 
tions, but  in  many  cases  of  gondrrhoeal  pus  a  striking  number  of  eosin- 
ophilic granulations  are  present. 

Pus  should  always  be  stained  for  tubercle  bacilli.  The  presence 
of  these  is  strongly  indicated  if  pus  is  present  in  the  absence  of  bac- 
teria and  of  other  cellular  elements.  The  more  carefully  and  thor- 
oughly the  staining  is  done  the  more  often  is  tuberculosis  found  to 
be  the  cause  of  pyuria.  The  best  clinical  staining  method  is  carbol- 
fuchsin  (Gabbett) :  the  cover-glass  is  smeared  with  a  dilute  solution 
of  egg  albumen ;  when  nearly  dry  a  drop  of  the  sediment  is  placed 
thereon,  dried,  and  flamed ;  it  is  then  stained  for  from  two  to  five 
minutes  with  carbol-fuchsin  (to  one  hundred  cubic  centimetres  of  a 
five  per  cent,  solution  of  carbolic  acid  add  one  gramme  of  basic  fuchsin 
dissolved  in  ten  cubic  centimetres  of  alcohol)  brought  to  the  steaming 
point ;  it  is  decolorized  with  acid  alcohol  (one  cubic  centimetre  of 
hydrochloric  acid,  ninety-nine  cubic  centimetres  of  seventy  per  cent, 
acid  alcohol)  and  counterstained  with  a  solution  of  alkaline  methylene 
blue  ;  the  tubercle  bacilli  are  red,  all  tissue  and  other  bacteria  are  blue. 
The  tubercle  bacilli  may  be  found  isolated;  more  commonly  they 
show  a  fasciculated  grouping.  (Fig.  114.)  Since  other  bacilh  show  this 
staining  reaction,  the  surest  method  is  by  inoculation  into  guinea-pigs. 

For  the  pyogenic  organisms  a  simple  watery  solution  of  methylene 
blue  or  any  other  basic  stain  suffices  ;  an  especially  good  general  bac- 
teria stain  is  prepared  by  adding  half  a  gramme  of  French  thionine  dis- 
solved in  ten  cubic  centimetres  of  alcohol  to  ninety  cubic  centimetres  of 
a  Ave  per  cent,  solution  of  carbolic  acid  ;  stain  for  a  few  minutes.  The 
colon  bacillus,  the  most  frequent  and  virulent  microbe  of  the  urinary 
tract,  appears  in  the  form  of  short  rods  with  rounded  ends,  irregularly 

23 


354  GENITO-UPvlNARr   DISEASES    AND    SYPHILIS. 

grouped  and  extracellular.      It  cannot  be  differentiated  by  staining 
from  other  organisms  of  the  bacillus  group. 

The  typical  gonococci  exist  as  reniform  diplococci  situated  within 
the  pus-cells  and  not  stained  by  Gram's  method.  In  the  early  stages 
of  inflammation  they  are  found  as  a  practically  pure  culture,  in  pus 
containing  little  or  no  epithelium  :  exceptionally  there  is  mixed  infec- 
tion Avith  the  ordinary  pyogenic  bacteria ;  later  squamous  and  tran- 
sitional epithelium  is  mixed  with  the  pus,  and  mixed  infection  is  the 
rule,  pseudo-gonococci  sometimes  appearing ;  these  are  extracellular 
and  are  larger  than  the  gonococci.  In  the  late  stages  of  chronic 
urethritis  gonococci  disappear,  many  different  microbes  then  being 
found  in  the  urine.  They  may  be  made  to  reappear  by  exciting  an 
acute  urethritis. 

To  determine  whether  or  not  an  albuminuria  depends  upon  py- 
uria, the  urine  should  be  added  to  an  equal  volume  of  one  per  cent, 
solution  of  acetic  acid  and  the  pus  thoroughly  mixed ;  then  a  pinch 
of  methyl-violet  is  added,  a  drop  is  placed  upon  the  ruled  slide  of  the 
Thoma-Zeiss  haemocytometer,  and  the  pus-cells  are  counted.  With 
another  portion  of  the  urine  an  albumen  estimation  is  made  with 
Esbach's  albuminometer ;  one  hundred  thousand  pus-cells  per  cubic 
centimetre  correspond  to  one  per  cent,  of  albumen.  If  the  pus-cells 
are  thoroughly  mixed  the  results  are  fairly  accurate.  The  greatest 
defect  of  the  method  is  dependent  on  the  inaccuracy  of  Esbach's 
albuminometer. 

Epithelium. — Normal  urine  contains  a  few  desquamated  cells,  es- 
pecially in  women.  The  large  squamous  cells  come  from  the  prepuce, 
the  meatus  urinarius,  and  the  vagina.  Large  cylindrical  cells  come 
from  the  urethra.  The  epithelial  cells  of  the  bladder,  urethra,  and 
pelvis  of  the  kidney  cannot  be  differentiated  in  urinary  sediment,  as 
they  are  of  the  same  type.  Those  of  the  superficial  layers  are  small 
cylindrical  cells  of  polygonal  form,  those  from  the  deeper  layers  are 
oval,  with  long  processes  ;  they  are  generally  more  or  less  degenerated. 
A  large  excess  of  these  generally  points  to  vesical  disease,  as  the  ureter 
and  pelvis  do  not  shed  so  many. 

The  cells  from  the  secreting  tubules  of  the  kidney  are,  as  a  rule, 
much  smaller  than  the  cells  of  the  subrenal  tract,  and  their  nuclei 
are  proportionately  larger  and  more  granular.  They  are  polygonal 
in  shape,  and  are  seen  in  all  degrees  of  degeneration.  They  may  occur 
isolated,  in  groups  as  shed,  or  in  the  form  of  epithelial  casts.  They 
indicate  nearly  always  an  inflammatory  and  degenerative  process  in 
the  kidneys.  Cylindrical  whorls  have  been  described  in  the  urine  of 
cases  of  "amyloid  kidney,  but  they  are  inconstant. 


EXAMINATION    OJP    THE    UKINE.  355 

Tissue  in  Urine. — In  some  cases  of  cystitis,  following  traumatism, 
prolonged  retention  of  urine,  protracted  and  obstructed  labor,  or  in- 
carceration of  a  retroverted  pregnant  uterus,  large  particles  of  necrotic 
bladder-tissue  may  be  passed  with  the  urine ;  not  only  mucous  mem- 
brane, but  fibrous  and  muscular  tissue  as  well.  Fragments  of  vesical 
cancer  and  papilloma  sometimes  appear.  In  renal  abscess  necrotic 
tissue  may  be  voided.  In  tubercular  nephritis  cheesy  detritus,  de- 
generated tissue,  and  fibrous  and  elastic  fibres  are  often  present. 
Renal  cysts  sometimes  empty  their  contents  into  the  urine.  Dermoid 
cysts  may  ulcerate  into  the  bladder  and  the  heterogeneous  contents 
be  expelled.     Fseces  are  seen  in  cases  of  recto-vesical  fistula. 

Parasites  and  Bacteria. — Echinococcus  cysts  of  the  kidney 
or  outside  of  it  may  empty  into  the  tract ;  there  will  be  a  gush  of  a 
milky  turbid  fluid  containing  a  high  percentage  of  albumen,  pus, 
blood,  and  the  booklets  of  the  entozoa.  In  rare  instances  small  por- 
tions of  tissue  or  concretions  may  be  passed.  These  attacks  may 
occur  periodically,  and  between  attacks  the  urine  may  present  no 
evidences  of  disease. 

In  the  tropics  the  distoma  haematobium  often  becomes  lodged  in 
the  mucous  membrane  of  the  ureter  or  bladder  and  gives  rise  to  hasma- 
turia,  pyuria,  often  lipuria,  and  discharges  its  eggs  into  the  urine.  The 
eustrongylus  gigas,  common  in  the  pelvis  of  the  kidney  of  canines, 
is  very  rare  in  man.  In  a  few  cases  nephrophagus  sanguinarius,  rhab- 
ditis  genitalis  (in  females),  and  psorosperms  have  been  found,  accom- 
panied by  hsematuria,  which  they  provoke. 

The  embryos  of  the  filaria  sanguinis  hominis  may  appear  in  the 
urine,  generally  enclosed  in  blood-clots,  and  accompanied  by  a  great 
deal  of  blood,  pus,  and  fat.  They  are  well  stained  by  the  basic  aniline 
dyes.     They  appear  in  the  urine  only  periodically. 

Normal  urine  in  the  bladder  contains  no  bacteria.  In  the  decom- 
position of  normal  urine  schizomycetes,  fermentation-germs,  and  the 
micrococcus  ureae  play  the  most  active  roles.  In  the  decomposition 
of  diabetic  urine  the  saccharomycetes  are  present  in  large  quantities, 
to  be  replaced  by  hyphomycetes  after  the  sugar  has  been  decom- 
posed. Many  forms  of  cocci,  bacilh,  and  spirilli  take  part  in  the  am- 
moniacal  decomposition ;  the  most  prominent  is  the  micrococcus 
urese,  which  forms  chains  or  rows  of  large  cocci.  Sarcinae  may  appear 
Ln  normal  urine. 

Pathogenic  Bacteria. — The  bacterium  coli  commune,  the  staphylo- 
coccus pyogenes  (generally  the  aureus),  the  streptococcus  pyogenes, 
and  the  proteus  Hauseri  are  the  most  common  pus-organisms.  The 
gonococci  may  come  from  the  urethra  or  from  the  bladder.     Rarely 


356  GEXITO-UEIXARY   DISEASES   AND   SYPHILIS. 

the  diplococcus  pneumoniae  and  the  spirillum  Obermeieri  have  been 
found  in  the  urine,  particularly  accompanying  a  haematuria.  The 
typhoid  bacillus  can  be  isolated  from  the  urine  early  in  the  disease, 
and  for  months,  sometimes  years,  after  convalescence. 

The  pus-organisms  may  be  found  in  any  case  of  inflammation  of 
the  mucous  membrane  of  the  urinary  tract,  in  acute  nephritis  and 
renal  abscess,  in  recto-vesical  fistula,  and  in  some  cases  of  pyaemia, 
erysipelas,  and  malignant  endocarditis. 

In  genito-urinary  tuberculosis  the  bacilli  may  appear  in  the  urine. 
A  portion  of  the  sediment  should  be  injected  into  the  subcutaneous 
abdominal  tissues  of  a  guinea-pig  and  the  animal  killed  in  from  three 
to  four  weeks  ;  from  the  enlarged  lymph-glands  or  tubercles  near  the 
point  of  injection  cover-glass  spreads  should  be  made  and  stained  with 
carbol-fuchsin  (Gabbett  method),  and  cultures  may  be  made  upon 
glycerin-agar.  If  the  bacilli  are  not  found  in  the  cover-glass  prepara- 
tions, sections  of  the  tissue  should  be  studied  histologically.  This 
method  should  be  employed  in  any  suspected  case  where  the  bacilli 
cannot  be  detected  in  the  sediment.  Tubercle  bacilli  may  be  found 
in  the  urine  of  acute  general  tuberculosis.  In  rare  cases  of  actino- 
mycosis of  the  urinary  tract  the  fungi  have  been  found  in  the  urine. 

The  tubercle  bacilli  must  be  distinguished  from  the  smegma  bacilli. 
Unfortunately,  this  is   almost  impossible  by  staining  methods. 

Urinary  Oasts. — Casts  should  always  be  viewed  as  pathological. 
While  it  is  true  that  they  are  sometimes  found  in  urine  free  from  albu- 
men coming  from  apparently  healthy  kidneys,  they  are  probably 
always  due  to  slight  circulatory  disturbances,  or  to  malnutrition  or 
toxic  irritation. 

Casts  are  of  the  following  varieties  :  hyaline  (including  cyhndroids), 
granular,  fatty,  waxy,  leucocytic,  blood,  epithelial,  amyloid,  and  bac- 
terial.    They  are  thus  amorphous,  granular,  or  cellular. 

Hyaline  casts  are  of  a  pale,  almost  transparent  appearance,  homo- 
geneous, the  edges  sharply  outhned,  and  stain  well  with  Lugol's  solu- 
tion and  the  acid  stains.  They  may  be  wide  or  narrow ;  as  a  rule, 
they  are  more  narrow  in  interstitial  nephritis,  and  more  wide  in  paren- 
chymatous nephritis.  Blood-cells,  pus-cehs,  urates,  epithelium,  and 
bacteria  often  adhere  to  them,  and  they  may  be  slightly  granular. 
Hyaline  casts  are  seen  in  the  urine  of  all  varieties  of  nephritis,  in  all 
degrees  of  arterial  and  venous  congestion,  in  renal  irritation  by  the 
toxins  of  the  infectious  diseases,  foods,  poisons,  digestive  diseases,  and 
in  auto-intoxication, — for  instance,  that  following  an  attack  of  epilepsy. 
They  therefore  do  not  indicate  an  inflammatory  nephritis.  Cyhndroids 
are  like  hyaline  casts  in  structure,  but  are  long  and  twisted  and  gen- 


EXAMINATION    OF   THE   URINE.  357 

erally  taper  to  a  point ;  they  may  accompany  hyaline  easts  in  any 
case,  but  are  most  common  in  children,  and  in  venous  congestion  of 
the  kidneys. 

Waxy,  coLLom,  and  AMYLom  casts  are  rare.  Waxy  casts  are  often 
long,  have  abrupt  broken  ends,  and  are  frequently  covered  with  cells 
and  crystals.  The  fibrin  casts  are  very  rare,  also  the  amyloid  casts, 
which  show  the  characteristic  stain-reaction  with  Lugol's  solution  or 
iodine-green  ;  but,  as  waxy  casts  often  take  a  tinge  of  these  stains, 
distinctions  are  frequently  difficult.  These  casts  always  indicate 
organic  renal  disease. 

Granular  casts  are  clinically  divided  into  the  pale  and  the  dark. 
The  granulations  consist  of  a  proteid  degeneration,  although  fatty  de- 
generation and  fat-drops  may  be  present  in  granular  casts.  They 
come  from  degenerated  epithelium  or  from  epithelial  casts.  They 
always  indicate  organic  kidney  disease,  and  are  most  abundant  in 
parenchymatous  nephritis. 

Epithelial  casts  are  probably  formed  by  a  desquamation  of  the 
tubular  epithelium,  which  makes  a  regular  mould,  with  the  edges  of 
cells  in  all  degrees  of  degeneration  closely  apposed.  When  the  de- 
generation is  extreme  the  cell  outlines  are  lost  and  a  granular  cast 
results.  They  occur  in  all  varieties  of  organic  renal  disease,  but 
especially  in  parenchymatous  nephritis. 

Blood-casts  are  formed  in  the  tubules  by  coagulated  blood,  and 
are  especially  seen  in  acute  nephritis ;  they  must  be  distinguished 
from  hyaline  casts  with  red  blood-cells  adherent  to  them.  Degener- 
ated blood-casts  become  granular  casts. 

True  leucocytic  casts  are  very  rare  ;  those  which  appear  as  such 
are  generally  hyaline  casts  covered  with  pus-cells. 

Bacterial  casts  consist  of  bacteria  massed  together,  and  look  like 
granular  casts,  but  are  easily  differentiated  by  staining ;  they  are  some- 
times seen  in  septic  nephritis  and  pyelonephritis. 

Unorganized  casts  of  blood-pigment  are  rarely  seen  in  the  urine 
of  cases  of  venous  renal  congestion.  Casts  of  urates  are  quite  common, 
and  signify  nothing  if  they  are  certainly  distinguishable  from  hyaline 
casts  covered  with  urates.  In  all  ammoniacal  urine  detritus  casts 
may  be  formed,  very  irregular  in  outline  and  appearance. 

Spermatozoa. — These  may  appear  in  the  urine  following  coitus 
(days  after  coitus  in  women).  Spermaturia  has  been  noted  in  tabes 
dorsalis,  trauma  or  inflammation  of  the  skin,  and  is  a  frequent  sequel 
of  epileptic  convulsions.  The  sperm  cells  are  generally  entangled  in 
the  threads  of  nucleo-albumin.  Congestion  or  inflammation  of  the 
prostatic  urethra  by  interfering  with  the  normal  tonicity  of  the  ejacu- 


358  GEXITO-URIXARY   DISEASES   AND    SYPHILIS. 

latory  ducts  is  the  usual  cause  for  the  spermaturia  noted  in  neu- 
rasthenics. They  are  exceptionally  accompanied  by  granules  and 
amyloid  bodies  from  the  prostate  gland.  The  latter  are  normal  in 
extreme  old  age ;  they  are  small,  round,  glistening,  yellowish-brown 
bodies,  which  may  form  the  nuclei  of  stones. 

Sago-bodies  of  globulin  are  also  seen  in  the  urine  of  cases  of 
true  spermatorrhoea ;  they  are  formed  and  exist  normally  in  the 
seminal  vesicles. 

CRYSTALLINE   SEDIMENT   OF   ACID    URINE. 

Urates. — The  crystalline  sediment  of  the  urine  depends  upon  the 
reaction.  In  acid  urine  a  reddish  precipitate  is  generally  composed 
of  urates  ;  if  the  color  of  the  urine  is  pale,  the  urate  sediment  is  cor- 
respondingly pale.  These  urates  will  pass  into  solution  if  the  urine 
is  warmed.  They  appear  as  the  acid  and  neutral  urates  of  ah  the 
normal  bases  of  the  urine,  and  are  generally  amorphous  in  form. 
They  form  flne  granules,  often  closely  packed  in  groups,  of  a  faint 
yellowish  color,  which  dissolve  when  the  urine  is  heated,  and  also 
dissolve  upon  the  addition  of  an  acid,  but  soon  reform  as  crystals  of 
uric  acid. 

The  urates  are  increased  in  febrile  states,  in  venous  renal  con- 
gestion, and  in  concentrated  urine.  They  frequently  form  calculi; 
sodium  urate  is  most  often  the  basis  of  concretions,  but  stones  of 
ammonium  urate  occur. 

Uric  Acid. — The  crystals  of  uric  acid  appear  in  many  forms : 
rhombic  tablets  with  broken  edges,  whetstone-shaped,  long,  needle- 
pointed  spars,  and  prismatic  forms  (which  are  the  most  characteristic) 
of  a  yellow  color,  often  cling  together  in  groups.  (Fig.  115.)  They 
may  be  colorless.  They  dissolve  upon  the  addition  of  an  alkali  (but 
not  of  ammonia),  and  crystallize  again  upon  the  addition  of  a  mineral 
acid.     They  also  react  to  the  murexide  test. 

Calcium  oxalates  appear  as  colorless  octahedral  or  dumb-bell  crys- 
tals, with  many  modifications  in  size  and  form.  (Fig.  115.)  They 
are  soluble  in  mineral  acids,  but  not  in  acetic  acid.  The  number  of 
crystals  bears  no  relation  to  the  amount  of  oxalic  acid  in  the  urine. 
Such  crystals  often  appear  in  healthy  urine.  They  are  formed  in 
excess  in  idiopathic  oxaluria. 

Calcium  sulphate  appears  as  long,  colorless  needles  ;  also  as  dumb- 
bells, insoluble  in  acids  or  ammonia.  These  crystals  are  rarely  seen, 
but  occur  in  the  urine  of  some  cases  of  calculus.  Calcium  carbonate 
occurs  also  as  dumb-bell  crystals. 

HippuRic   ACID    appears   rarely  in   the  form  of  rhombic  crystals. 


Fig.  115. 


Sediment  of  acid,  urine. 
A.  Uric  acid  crystals.    B.  Amorphous  urates. 


Sediment  of  acid  urine. 
A.  Oxalates.    B.  "Uric  acid.     C.  Sodium  urate. 


Sediment  of  alkaline  urine. 
A  and  B.  Triple  phosphates.     C.  Ammonium  urates. 


EXAMINATION    OF   THE    UKINE.  359 

soluble  in  ammonia,  but  not  in  acids :  these  crystals  follow  the  inges- 
tion of  benzoic  acid  and  of  the  many  fruits  which  contain  it. 

Bilirubin  or  hsematoidin  crystals  are  small,  yellowish-red,  rhom- 
bic forms,  or  bunched  needles ;  sometimes,  also,  yellowish-brown, 
amorphous  masses.  They  are  soluble  in  an  alkali  or  in  chloroform, 
and  they  respond  to  Graelin's  test.  They  are  present  in  some  cases 
of  jaundiced  urine,  in  acute  yellow  atrophy  of  the  liver,  and  in  acute 
phosphorus  poisoning ;  also  in  severe  cases  of  the  infectious  dis- 
eases. 

They  are  often  seen  attached  to  cellular  elements,  and  then  sug- 
gest some  local  lesions  of  the  urinary  tract ;  they  have  thus  been  seen 
in  pyelonephritis,  cystic  kidneys,  cancer  of  the  bladder,  renal  or  vesi- 
cal tuberculosis,  and  severe  toxic  nephritis. 

Leucjn  and  Tyrosin. — Leucin  is  generally  in  solution  in  the  urine, 
but  may  ppear  as  round  balls  of  crystalline  structure.  If  a  solution 
is  warmed  with  mercury  oxydul-sulphite  the  mercury  will  in  the 
presence  of  leucin  be  thrown  down  in  the  metaUic  state. 

Tyrosin  appears  as  bunches  of  needles,  insoluble  in  acetic  acid, 
but  soluble  in  ammonia  and  hydrochloric  acid.  The  collected  crys- 
tals should  be  dissolved  in  ammonia,  recrystallized  by  evaporation, 
and  then  submitted  to  Millon's  reagent,  to  which  they  respond  posi- 
tively. 

Leucin  and  tyrosin  are  found  in  cases  of  acute  yellow  atrophy  of 
the  liver,  in  acute  phosphorus  poisoning,  in  internal  gangrene,  and  in 
severe  cases  of  the  infectious  diseases. 

Cystin. — In  all  cases  leucin  and  tyrosin  are  accompanied  by 
cystin,  but  cystin  may  appear  alone.  Cystin  crystals  look  like  those 
of  uric  acid,  but  differ  in  that  they  are  soluble  in  ammonia.  They 
are  insoluble  in  acetic  acid  and  alcohol,  and  polarize  light  to  the 
left. 

Cystin  crystals  appear  in  the  urine  in  the  severe  bacterial  infec- 
tions, in  gangrene,  and  in  idiopathic  cystinuria.  They  may  form  a 
calculus. 

The  soaps  of  calcium  and  magnesium  occur  occasionally,  and  form 
crystals  which  resemble  those  of  tyrosin  and  cystin,  but  do  not  give 
their  reactions. 

An  excess  of  xanthin  bases  in  the  urine  may  form  a  sediment  of 
crystals  which  resemble  those  of  uric  acid,  but  are  soluble  in  ammonia ; 
they  may  form  calculi. 

In  faintly  acid  or  neutral  urines  certain  crystals  form^  which  are  to 
be  classed  with  the  alkaline  sediment.  They  are  triple  phosphates, 
basic  magnesium  phosphates,  and  neutral  calcium  phosphates ;  they 


360  GENITO-TJEINARY   DISEASES   AND    SYPHILIS. 

form  especially  when  the  urine  is  becoming  alkaline.     An  excess  of 
the  crystujs  of  triple  phosphates  in  acid  urine  suggests  phosphaturia, 

SEDIMENT   OF   ALKALINE   URINE. 

Phosphates. — The  acid  or  basic  phosphates  may  be  amorphous, 
small  granules.  The  acid  calcium  phosphate,  a  rare  form,  is  present 
in  the  urine  of  those  suffering  from  imperfect  nutrition.  Triple  phos- 
phates may  be  seen  in  weak  acid,  neutral,  or  alkaline  urine ;  most 
marked  in  alkaline  decomposition.  They  are  large  octahedral  or  pris- 
matic forms,  but  in  ammoniacal  urine  present  innumerable  varieties. 
(Fig,  115.)  The  basic  magnesium  phosphate  appears  as  refractive 
rhombic  tablets.  The  neutral  calcium  phosphate  is  generally  in  the 
form  of  large  needles  or  prisms  massed  together.  These  forms  all 
intermingle  and  have  endless  variations.  Phosphates  are  dissolved 
by  acids ;  they  commonly  constitute  the  outer  coats  of  nearly  all 
vesical  calculi,  but  may  form  the  entire  stone. 

Ammonium  urates  (Fig.  115)  appear  as  round  balls  of  dark  color, 
often  with  spicules.  They  rarely  form  calculi.  Dissolved  in  acetic 
acid  they  recrystallize  as  rhombic  uric  acid. 

The  carbonates  of  the  alkaline  earths  appear  in  the  urine  as 
dark  masses  of  granules  ;  they  dissolve  with  effervescence  in  acetic 
acid. 

CnoLESTEmN  crystals  may  occur  in  urine  of  any  reaction,  but  are 
seen  most  typically  in  alkaluie  urine.  Exceptionally  they  occur  in 
severe  cystitis  and  in  chyluria.  They  appear  as  flat  plates,  with 
broken  or  cut-out  cornels. 

Indigo  crystals  may  form  in  the  alkaline  urine  of  normal  subjects, 
but  when  found  Li  acid  urine  they  suggest  an  excess  of  indosulphuric 
acid  and  th?  allied  aromatic  compounds  of  the  ether-sulphate  series, 
due  to  tissue-decomposition,  such  as  internal  suppuration,  gangrene, 
■jtc.     They  appear  as  fine  blue  needles  and  crystals. 

TECHNIQUE    OF    EXAMINATION    OF    URINE    FOR    THE    USUAL    PATHO- 
LOGICAL  CONSTITUENTS. 

Specific  Gravity. — Apparatus  required. — A  urinometer,  suitably- 
graduated,  with  a  cylinder  having  fluted  walls,  which  will  prevent  the 
urinometer  from  adhering  to  its  sides.  The  form  made  by  Squibb  is 
convenient.  A  thermometer,  either  attached  to  the  urinometer  stem 
or  independent. 

The  cylinder  must  be  clean  and  dry,  or  else"  its  Avails  must  be 
moistened  with  the  urine  to  be  examined.  Insert  the  dry  urinometer 
slowly  and  note  that  it  floats  freely  in  the  liquid.     When  at  rest  read 


EXAMINATION    OF   THE    URINE.  361 

on  the  scale  enclosed  in  the  urinometer  stem  the  level  at  which  the 
liquid  stands.  Generally,  a  urinometer  is  so  graduated  that  1000  rep- 
resents the  density  of  distilled  water,  and  each  chief  division  on  the 
stem  is  subdivided  into  ten  parts. 

The  density  of  a  liquid  varies  with  the  temperature ;  hence  a 
standard  temperature  at  which  the  urinometer  is  normal  is  indicated 
on  the  stem  of  the  instrument.  This  is  usually  60°  F.,  or  15°  C. 
If  the  urine  to  be  tested  is  above  or  below  this  standard  a  tempera- 
ture correction  must  be  made.  For  clinical  purposes  the  following 
method  will  be  found  sufficiently  accurate. 

For  every  three  degrees  centigrade  above  the  normal  add  one  to 
the  decimal  of  the  last  order;  for  every  three  degrees  below  the 
normal  subtract  one  from  the  decimal  of  the  last  order.  For  exam- 
ple :  Temperature  observed  =  18°  C. ;  normal  temperature  =^  15°  C. ; 
observed  reading  =:  1014;  corrected  reading  =  1015. 

Since  the  specific  gravity  varies  inversely  as  the  volume  of  urine, 
a  correction  should  also  be  made  for  such  variation,  accepting  a  given 
quantity  as  normal.  1200  c.c.  is  the  usual  amount,  and  the  total 
volume,  if  differing  from  this,  should  be  reduced  to  such  a  standard. 
The  formula  for  correction  is  as  follows  : 

Volume  of  urine  X  last  two  decimals  of  observed  specific  gravity. 

1200 

For  instance,  the  volume   of  urine   excreted  in  twenty-four  hours 

amounts  to  1450  c.c. ;  the  observed  specific  gravity  at  15°  C.  is  1015. 

1450  X  15 

=  18.     Therefore  the  specific  gravity  of  the  urine  is  1018 

1200  ^  ^  ^ 

for  1200  c.c.     Results  so  calculated  enable  one  to  compare  accurately 

the  data  obtained  from  day  to  day  regardless  of  the  variation  in  volume. 

Reaction. — The  urine  must  be  fresh  if  a  correct  idea  regarding  the 
presence  of  acid  or  alkaline  reacting  salts  is  to  be  formed. 

The  most  suitable  indicator  for  urine  is  litmus.  Into  the  specimen 
to  be  examined  introduce  two  small  slips  of  litmus  paper,  one  red 
and  one  blue.  A  reddening  of  the  blue  slip  shows  acidity.  A  bluing 
of  the  red  slip  is  due  to  a  preponderance  of  alkaline  salts.  These 
may  be  salts  of  the  fixed  alkalies,  most  commonly  disodium  hydrogen 
phosphate,  or  ammonium  carbonate  formed  by  decomposition  of  urea 
either  inside  the  bladder  or  after  the  urine  has  been  voided.  If  it  is 
ammonium  carbonate  the  red  color  of  the  litmus  will  return  on 
drying ;  the  blue  color  formed  by  the  sodium  phosphate  is  permanent. 

Albumen  in  Urine. — Apparatus  and  Reagents. — A  funnel,  about 
three  inches  in  diameter ;  filter  paper ;  test-tubes,  preferably  six  inches 


362  GENITO-UFvINAEY   DISEASES   AND   SYPHILIS. 

long  by  three-quarters  of  an  inch  in  diameter ;  Bunsen  burner ;  conical 
glass  vessel ;  pipette. 

Concentrated  nitric  acid;  0.5  per  cent,  acetic  acid;  concentrated 
acetic  acid ;  potassium  ferrocyanide,  ten  per  cent,  solution. 

Preliminaries. — Filter  the  urine,  making  sure  that  it  is  finally  per- 
fedly  dear.  Determine  the  reaction  by  means  of  litmus  paper.  If 
alkaline,  cautiously  add  0.5  per  cent,  acetic  acid  until  the  reaction  is 
distinctly  acid ;  if  originally  acid,  proceed  directly  to  the  following  tests  : 
Boil  about  five  cubic  centimetres  of  urine  in  a  test-tube.  Note 
any  cloudiness  produced  by  heat.  To  the  urine  so  clouded  add  a 
few  drops  of  dilute  acetic  acid.  Phosphates  will  be  dissolved  by  this 
reagent ;  albumen  is  not  altered,  therefore  any  remaining  cloud  is  due 
to  albumen  and  urinary  mucin  (nucleo-albumen)  together. 

A  more  delicate  test  is  to  add  to  the  urine,  acid  in  reaction  and 
almost  boiling  hot,  a  drop  of  concentrated  nitric  acid.  If  a  cloud  is 
not  produced,  add  a  second  drop  and  again  examine  in  a  good  light. 
Continue  this  procedure  until  about  fifteen  drops  of  nitric  acid  have 
been  slowly  added  to  the  hot  urine.  A  precipitate  so  formed  is 
albumen  or  globulin,  not  mucin.  It  is  well  to  stand  the  tube  aside 
for  an  hour  or  two  and  examine  at  the  expiration  of  that  time  for 
cloudiness.  If  a  clouding  has  taken  place  heat  again,  carefully.  A 
resolution  of  it  indicates  an  albumose ;  a  permanent  precipitate  is 
referable  to  albumen  or  globulin. 

Heller's  Test. — Into  a  conical  glass  vessel  of  about  50  c.c.  capacity 
put  a  few  cubic  centimetres  of  concentrated  nitric  acid.  On  the  sur- 
face of  the  acid  float  20  to  30  c.c.  of  the  filtered  urine.  That  the  two 
layers  may  not  mix,  it  is  advisable  to  add  -the  urine  from  a  pipette, 
letting  it  flow  slowly  down  the  side  of  the  vessel.  A  homogeneous 
white  ring,  of  greater  or  less  density,  will  form  at  the  junction  of  the 
two  layers  if  albumen  is  present. 

Common  Fallacies. —  Urea  nitrate  may,  in  concentrated  specimens, 
form  a  ring,  but  this  is  crystalline,  not  homogeneous,  as  is  the  albumen 
ring. 

In  highly  pigmented  samples,  as  in  those  containing  bile  or  indican, 
there  is  variously  colored  zona,  not  albuminous,  bordering  the  nitric 
acid. 

A  faint,  waving  ring,  one  to  two  centimetres  above  the  nitric  acid, 
and  which  gradually  progresses  upward,  is  due  to  uric  acid.  Still 
farther  from  the  nitric  acid  layer  a  band  of  mucin  may  be  seen. 

The  pine  acids  are  precipitated  by  nitric  acid,  but  may  be  distin- 
guished from  albumen  by  their  solubility  in  alcohol  or  ether. 

Potassium   Ferrocyanide   Test. — Make  the  clear  urine  distinctly 


EXAMINATION    OF    THE    URINE.  3^3 

acid.  Add  a  few  drops  of  a  ten  per  cent,  solution  of  potassium 
ferrocyanide.  In  the  presence  of  albumen,  globulin,  or  albumose  a 
cloud  or  a  precipitate  will  be  formed. 

For  an  emergency  test  an  aqueous  solution  of  metaphosphoric 
acid  may  be  used  by  the  contact  method  ;  for  this  purpose  solid 
metaphosphoric  acid  should  be  carried  and  a  solution  prepared  when 
needed.     Picric  acid  may  be  used  in  a  similar  manner. 

The  corrosive  mercuric  chloride  solution  made  from  the  ordinary 
antiseptic  corrosive  chloride-tartaric  acid  tablets  affords  another  ready 
and  very  delicate  test.  Mercury  is  indeed  one  of  the  most  delicate 
reagents  for  albumen,  and  it  has  found  its  most  perfect  application  in 
Spiegler's  solution :  hydrarg.  chlor.  corros.,  8 ;  acid,  tartar.,  4 ;  glyce- 
rinum,  20  ;  aqua,  400  (this  must  be  fresh ;  it  spoils  in  ten  days).  To 
the  urine  a  few  drops  of  acetic  acid  are  added ;  it  is  then  filtered  ;  the 
filtrate  is  applied  to  the  reagent  by  the  contact  method ;  if  albumen  is 
present  a  white  ring  forms.  In  the  appHcation  of  this  method  it  must 
be  borne  in  mind  that  it  is  so  deMcate  that  the  slightest  amount  of  al- 
bumen is  detected  by  it,  and  it  is  therefore  best  reserved  for  special 
cases,  as  one  might  otherwise  be  led  by  it  into  too  frequent  diagnosis 
of  urinary  disease.  A  pathological  albuminuria  which  can  be  de- 
tected by  Spiegler's  reagent  will  usually  show  by  the  ferrocyanide  test. 

These  methods  will  detect  serum-albumen,  globulin,  and  primary 
albumoses  ;  the  last  reacts  also  to  the  deutero-albumoses  and  to  pep- 
tone. 

The  quantitative  estimation  of  albumen  can  be  made  by  the  pre- 
cipitation by  heat  and  acetic  acid,  following  which  the  albumen  is 
carefully  washed  with  alcohol  and  ether,  dried,  and  weighed.  The 
results  of  estimations  by  Esbach's  albuminometer  are  no  more  accu- 
rate than  those  obtained  by  careful  observation  of  the  intensity  of  the 
reactions  to  the  above-given  tests. 

Globulin  can  be  precipitated  from  the  other  proteids  by  one-half 
saturation  with  ammonium  sulphate ;  this  precipitate  is  washed, 
dried,  and  weighed ;  the  weight  compared  with  the  weight  of  the  total 
albumen  will  give  the  serum-albumen-globulin  ratio. 

Albumoses. — In  testing  for  albumoses  the  urine  must  be  fresh, 
as  the  natural  enzymes  of  the  urine  or  bacteria  can  produce  albumoses 
from  albumen.  Since  semen  contains  albumoses,  this  must  be  excluded. 
If  albumen  be  present  it  should  be  removed  by  simply  boiling,  and  the 
urine  filtered  while  hot  and  boiled  down.  To  the  hot  filtrate  ammo- 
nium sulphate  should  be  carefully  added  up  to  complete  saturation, 
and  any  precipitate  collected  upon  a  filter  and  dissolved  in  distilled 
water.     To  this  solution  is  then  added  an  equal  amount  of  a  con- 


364  GENITO-URINARY   DISEASES   AND    SYPHILIS. 

centrated  sodium  chloride  solution  and  of  acetic  acid  a  few  drops  at  a 
time,  as  long  as  the  precipitate  forms  ;  the  solution  is  then  boiled.  If 
on  boiling  the  precipitate  is  lessened  or  disappears,  to  reappear,  after 
filtration  while  hot,  in  the  cooled  filtrate,  albumoses  are  present  if  the 
filtrate  responds  to  the  biuret  test  or  Millon's  reagent. 

Sugar  in  Urine. — Apparatus  and  Reagents. — Funnel;  filter  paper; 
test-tubes  ;  pipette ;  small  measuring  cylinder ;  Bunsen  burner. 

Fehling's  Solution. — This  consists  of  two  solutions.  No.  1  con- 
taining 34.639  grammes  of  copper  sulphate  in  500  c.c.  of  distilled 
water;  No.  2,  175  grammes  of  sodium  potassium  tartrate  (Rochelle 
salt)  and  60  grammes  of  caustic  soda  in  500  c.c.  of  water.  Preserve 
in  separate  bottles. 

Almen's  Solution. — Four  grammes  of  Rochelle  salt,  2  grammes  of 
bismuth  subnitrate,  10  grammes  sodium  hydrate,  and  90  c.c.  of  water. 
Boil,  filter,  and  preserve  in  a  colored  glass  bottle. 

Preliminaries. — Filter  the  sample  before  testing.  Be  sure  that  it 
is  perfectly  fresh.  The  best  preservative  is  a  few  crystals  of  very 
finely  powdered  thymol.  Chloroform,  formalin,  salicylic  acid,  etc., 
will  themselves  act  upon  the  reagents.  Always  remove  albumen,  if 
this  substance  be  present,  by  heating  the  sample  with  acetic  acid  and 
filtering  off  the  precipitate.  Then  neutralize  with  a  few  drops  of 
caustic  soda  or  potash. 

Fehling's  Test. — Mix  together  equal  quantities  of  Fehling's  solu- 
tions, Nos.  1  and  2,  and  dilute  the  mixture  with  three  times  its  volume 
of  water.     This  mixture  should  be  freshly  prepared  each  day. 

Boil  three  to  five  cubic  centimetres  of  the  solution  in  a  test-tube. 
The  deep  blue  color  should  not  change.  To  the  very  hot,  but  not 
boiling,  solution  add  one  drop  of  the  urine  to  be  tested.  In  the 
presence  of  a  considerable  quantity  of  sugar  a  red  or  bright  yellow 
precipitate  of  copper  suboxide,  CuO,  will  come  down  immediately. 
Smaller  amounts  may  necessitate  the  addition  of  several  drops  or 
even  more  before  a  precipitation  occurs.  If  no  precipitate  appears 
after  a  volume  of  urine  equal  to  the  volume  of  Fehling's  solution  has 
been  added,  the  test-tube  being  kept  hot  all  the  while  but  not  boiled, 
the  test  is  negative.  The  precipitate  must  be  red  or  yellow  in  color 
to  indicate  sugar. 

Common  Fallacies. — A  flocculent  precipitate  having  a  greenish  tinge, 
and  most  frequently  due  to  earthy  phosphates,  which  is  not  yellow 
nor  red  and  not  granular,  therefore  not  a  reduction  due  to  sugar. 

A  yellow  solution,  without  a  precipitate,  formed  after  rather  large 
quantities  of  urine  have  been  added.  This  is  due  to  reducing  sub- 
stances in  the  urine  which  are  not,  however,  sugar. 


EXAMINATION    OF    THE    URINE.  365 

Salicylates,  which  reduce  Fehling's  reagent  just  as  glucose  does. 

Creatinin,  which  may  hold  in  solution  a  small  quantity  of  copper 
suboxide,  and  prevent  a  little  sugar  from  being  observed. 

Uric  acid,  which  in  boiling  solution  reduces  Fehling's. 

Albumen,  which  forms  a  precipitate  with  the  copper  salt.  This 
precipitate  is  white. 

Bottger's  Test,  using  Almen's  Solution. — Boil  10  c.c.  of  the  sus- 
pected urine.  To  the  hot  liquid  add  1  c.c.  of  the  reagent  prepared 
as  above  outlined.  Boil  again ;  glucose  will  cause  a  precipitate  of 
bismuth,  black  in  color.  If  a  trace  of  sugar  only  is  present  the  liquid 
will  turn  brown  or  black,  and  longer  boiling  is  necessary  to  detect  the 
smaller  cfuantity.  It  is  well  also  to  stand  the  tube  aside  for  at  least 
half  an  hour,  when  another  observation  should  be  made.  A  negative 
reaction  with  this  test  shows  sugar  to  be  clinically  absent ;  a  positive 
reaction  should  be  further  confirmed. 

Common  Fallacies. — Albumen,  which  by  decomposition  gives  a 
black  sulphide  of  bismuth,  in  appearance  not  to  be  distinguished  from 
the  sugar-formed  precipitate. 

Glycosuric  acid,  which  blackens  the  reagent ;  also  sulphur  com- 
pounds in  urine,  not  sulphates. 

Fermentation  Test. — Fill  a  fermentation-tube  (a  Doremus  ureome- 
ter  will  serve)  with  the  suspected  urine  which  has  previously  been 
well  shaken  with  a  small  piece  of  a  fresh  yeast-cake.  Stand  in  a 
warm  place  for  twelve  to  twenty-four  hours.  Any  gas  which  forms 
will  collect  at  the  upper  end  of  the  tube,  and,  being  carbon  dioxide, 
indicates  the  former  presence  of  glucose  which  has  been  fermented 
by  the  yeast.  A  control-tube  containing  yeast  and  water  should  be 
made  also,  as  the  yeast  preparation  may  contain  sugar. 

Indican. — Jaffe's  Test. — Reagents. — Concentrated  hydrochloric 
acid  ;  potassium  permanganate,  of  such  strength  that  when  the  column 
of  liquid  in  a  test-tube  is  held  against  the  light  it  is  a  transparent, 
clear  purple ;  chloroform. 

Preliminary  Treatment. — If  bile  is  present  remove  it  by  adding 
subacetate  of  lead,  avoiding  an  excess,  and  filtering.  Iodides  must 
also  be  ehminated.  Accomplish  this  by  the  addition  of  a  little  silver 
nitrate  and  filter  off  the  precipitate. 

To  5  c.c.  of  clear  urine  add  5  c.c.  of  hydrochloric  acid ;  shake 
well  and  add  one  drojy  of  potassium  permanganate.  The  urine  may 
or  may  not  appear  blue.  In  any  case  add  about  1  c.c.  of  chloroform, 
stopper  the  tube,  and  shake  well.  The  chloroform  will  absorb  the 
indican  and  will  be  colored  blue,  the  depth  of  coloring  indicating  the 
amount  of  indican  present. 


366  GENITO-URII^ARY    DISEASES   AiVD   SYPHILIS. 

Bile  Pigment. — Gmelin's  Test. — To  a  few  drops  of  the  filtered 
urine  on  a  white  porcelain  surface  add  one  drop  of  fuming  nitric  acid. 
A  color  play,  green,  blue,  violet,  red,  and  yellow,  the  colors  present- 
ing themselves  in  rings  in  the  order  named,  will  be  observed  if  bile 
is  present.  Green  is  indispensable  ;  the  other  tints  may  be  simulated 
by  pigments  not  biliary. 

The  drop  of  nitric  acid  may  be  applied  to  a  piece  of  pure  Swedish 
filter  paper  through  which  the  urine  has  been  passed.  The  color 
rings  then  appear  as  above  given. 

Blood  Coloring  Matter. — Reagents. — Tincture  of  guaiacum  and 
ozonized  ether  or  old  oil  of  turpentine. 

Mix  in  a  test-tube  equal  parts  of  guaiac  and  ozonized  ether  or 
turpentine.  Float  over  this  a  layer  of  the  urine  to  be  tested,  avoiding 
any  mixing  of  the  two  layers.  A  white  ring,  turning  blue,  appears  at 
the  point  of  contact  if  blood  is  present.  Heat  does  not  cause  it  to 
disappear.  Pus  also  gives  a  blue  ring,  but  heat  destroys  the  color, 
and  the  guaiac  alone  is  sufficient  to  produce  it. 

Another  test  is  the  addition  of  a  few  drops  of  sodium  hydrate, 
which,  precipitating  the  phosphates,  brings  down  also  -the  blood 
coloring  matter  as  a  pink  or  brownish  deposit.  Warming  hastens  the 
precipitation. 

Heller's  test :  Add  NaOH  to  the  urine  until  distinctly  alkaline ; 
boil  and  cool  rapidly.  If  heemoglobin  is  present  it  will  be  precipitated 
with  the  phosphates  and  appear  as  a  red  or  brownish  sediment. 
Spectroscopically  the  absorption  bands  are  generally  those  of  methae- 
moglobin,  not  haemoglobin. 

Ehrlich's  Diazo  Reaction. — Reagents. — Fifty  cubic  centimetres 
of  concentrated  hydrochloric  acid  diluted  to  1000  c.c.  with  water  and 
saturated  with  sulphanilic  acid ;  a  0.5  per  cent,  solution  of  sodium 
nitrite. 

Mix  together  40  c.c.  of  the  sulphanilic  acid  mixture  and  1  c.c.  of 
the  nitrite  solution.  To  a  few  cubic  centimetres  of  the  urine  in  a 
test-tube  add  an  equal  volume  of  the  reagent  and  shake  well.  Care- 
fully float  two  to  three  cubic  centimetres  of  ammonium  hydrate  on 
the  surface  of  the  liquid.  A  sharply  defined  ring  appears  at  the  point 
of  contact,  yellow  if  the  reaction  is  negative,  a  brilliant  carmine  red 
if  positive.  As  a  confirmatory  test  pour  the  contents  of  the  tube  in 
a  large  porcelain  dish  containing  water.  A  salmon-pink  color  will  be 
seen  if  the  chromogen  is  present.  This  is  a  very  delicate  reaction, 
the  pink  tinge  showing  very  often  when  the  ring  color  is  indistinct. 


CHAPTER   IX. 

CYSTOSCOPY. EXAMINATION     OF    URINE     FROM     EACH    KIDNEY     SEPARATELY. 

RENAL    CAPABILITY. SURGICAL    TREATMENT    OF    NEPHRITIS. 

Visual  examination  of  the  bladder  through  the  urethra  was  first 
made  practicable  by  Dr.  Max  Nitze,  of  Berlin.  Cystoscopes,  as  now 
made,  are  from  ten  to  a  little  over  eleven  inches  long,  terminating  in 
short  beaks,  three-fourths  of  an  inch  long,  which  contain  the  illumi- 
nating apparatus,  an  incandescent  lamp,  and  the  window  through 
which  the  bladder  can  be  seen.     (Fig.  116.)     The  shafts  of  the  in- 

FiG.  116. 


Aero-cystoscope. 


struments  contain  the  optical  apparatus.  The  calibre  of  the  cys- 
toscopes is  from  22  F.  to  25  F.  The  beak  makes  an  angle  of  one 
hundred  and  forty-five  degrees  with  the  shaft,  and  the  window  and 
electric  light  are  usually  on  the  inner  surface  of  the  beak.  Through 
the  window  the  opposite  section  of  the  bladder-wall  is  reflected  upon 
the  hypothenuse  of  a  right-angled  prism,  and  thence  through  the 
shaft  of  the  instrument  to  the  eye  of  the  observer.  The  minute  in- 
verted image,  righted  and  focussed  at  the  ocular  end  of  the  instru- 
ment by  means  of  two  plano-convex  lenses,  is  finally  magnified  by  a 
lens  in  the  funnel-shaped  eye-piece. 

The  window  and  light  are  sometimes  placed  on  the  outer  surface 
of  the  beak,  thus  bringing  the  base  of  the  bladder  directly  into  view. 
(Fig.  117.) 

Some  cystoscopes  are  provided  with  a  channel  through  which 


368 


GE^'ITO-URINARY   DISEASES  AND   SYPHILIS. 


the  bladder  can  be  irrigated,  thus  enabling  this  viscus  to  be  seen 
under  varying  degrees  of  tension,  and  providing  the  surgeon  with 
a  means  of  evacuating  the  fluid  contained  in  the  bladder,  should  it 


Fig.  117. 


Cystoscope  with  the  light  and  \rindow  on  the  outer  aspect  of  the  beak. 

become  turbid,  and  replacing  it  with  a  clear  fluid,  without  removing 
the  instrument.  There  is  also  a  catheterizing  cystoscope,  provided 
with  canals  through  which  can  be  passed  ureteral  catheters,  an  aero- 
cystoscope  for  direct  inspection,  of  American  make,  and  an  operating 
cystoscope,  which  enables  the  surgeon  to  remove  small  outgrowths 
from  the  vesical  mugosa. 

In  choosing  instruments  it  is  well  to  see  that  the  optical  apparatus 
gives  a  perfectly  clear  picture,  and  that  the  incandescent  lamp  is  in 
good  working  order.  Some  instruments  are  so  constructed  that  should 
the  lamps  burn  out  the  tips  containing  them  will  have  to  be  sent  to 
the  manufacturer  for  the  insertion  of  new  lamps.  It  is  desirable  either 
to  secure  a  number  of  tips,  or  to  purchase  a,n  instrument  to  which  a 
new  lamp  can  be  attached  by  any  instrument-maker. 

If  the  surgeon  expects  to  make  many  cystoscopic  examinations, 
he  will  need  at  least  three  instruments. 

When  but  a  single  instrument  is  used,  this  should  be  supplied 
with  the  irrigating  apparatus,  and  should  have  the  window  and  lamp 
on  the  concave  side  of  the  flexure.  As  a  rule,  it  is  well  to  become 
accustomed  to  the  use  of  one  instrument  before  trying  others. 

The  catheterizing  cystoscope  should  enable  the  operator  to  cathe- 
terize  both  ureters  at  the  same  time  (Figs.  118,  119,  120),  though  this 
in  diseased  conditions  of  the  bladder  is  often  impracticable.  As  the 
source  of  Mght,  a  storage  battery  supplied  with  a  rheostat  should  be 
used.     An  ordinary  immersion  battery  will,  however,  prove  satisfactory. 

Immediately  after  being  used,  the  shaft  and  beak  of  the  instrument 
are    cleansed  with   soap  and  hot  water,   particular   attention   being 


CYSTOSCOPY. 


369 


directed  to  flushing  the  catheterizing  canals ;  the  latter  should  be 
washed  out  with  a  five  per  cent,  formol  solution.  The  instrument  is 
thoroughly  dried,  either  in  an  oven  or  in  a  receptacle  containing  calcium 
chloride,  and  is  finally  stored  in  a  paraform  disinfecting  box. 

Method  of  using  the  Cystoscope. — When  required  for  use,  the  cysto- 
scope  is  attached  to  the  battery,  and  the  current  is  turned  on  till  the 
lamp  burns  with  a  bright  white  light ;  the  current  is  then  turned  off. 


Fig.  118. 


Fig.  119. 


Bierhoff's  Catheterizing  Cystoscope ;  Voltage,  6-8 ;  Lens,  round ;  Large  field  ;  Clear  defination. 


The  shaft  of  the  instrument  is  dipped  in  sterile  water  or- boric  acid 
solution,  is  wiped  dry  Avith  a  sterile  towel,  is  lubricated  with  glycerin, 
and  is  introduced  into  the  bladder ;  not  till  its  shoulder  has  passed 
entirely  within  the  viscus  is  the  light  turned  on.  To  make  a  satisfac- 
tory examination  of  the  bladder  it  is  essential  that  it  should  contain 
at  least  four  ounces  of  clear  fluid,  and  that  the  urethra  should  be  suffi- 

24 


370 


GENITO-UEIISrARY   DISEASES   AND    SYPHILIS. 


ciently  capacious  and  direct  in  course  to  admit  the  cystoscope  (28  F.). 
Twenty  grains  of  antipyrin  and  ten  minims  of  laudanum  in  an  ounce 
of  water  injected  into  the  rectum  forty-five  minutes  before  operation 
is  an  excellent  adjunct  to  local  anaesthesia. 

The  aero-cystoscope  is  passed  into  an  empty  bladder,  the  patient 

Fig.  120. 


Eisner's  catheterizing  cystoscope. 

being  in  the  knee-chest  or  Trendelenburg  position.  Local  anaesthesia 
by  means  of  eucaine  usually  makes  the  procedure  bearable.  Four 
drachms  of  a  twenty  per  cent,  solution  of  this  drug  injected  through 
the  catheter  or  the  irrigating  cystoscope  are  recommended  by  Fenwick, 
but  a  better  and  safer  way  of  applying  this  is  by  means  of  the  instil- 
lator :  the  barrel  of  this  instrument  is  filled  with  a  four  per  cent,  solu- 


FiG.  121. 


Pryor's  cystoscope  for  the  female. 

tion  of  eucaine,  the  catheter  end  is  then  introduced  into  the  urethra, 
and  as  soon  as  pain  is  experienced  one  or  two  drops  are  injected. 
When  the  prostatic  urethra  is  reached,  a  drachm  of  the  eucaine  solu- 
tion is  injected,  the  syringe  being  removed  from  the  catheter  as  often 
as  is  necessary  for  refilling. 

The   urine,  when   it  is   clear,  is  the   most   satisfactory  medium 


Fig.  122. 


s2= 


sd 


A,  Male  ureter-cystoscope ;  B,  female  ureter-cystoscope ;  C,  windows  of  both ;  D,  periscope 
or  telescope;  E,  obturator  of  male  instrument.  1,  Handle  for  electric  connection;  2,  catheters 
projecting  from  ureter-tubes;  3,  air-tube  and  cock. 


Bransford-  Lewis  Ureter-  Cystoscope. 

Fig.  123. 


1.  Aluminum  swab  or  applicator;  2,  urethral  tablet  depositor  and  obturators;  3,  aspirator; 
4,  inflating  bulbs  with  metal  extremity  for  receiving  warm  air  ;  5,  syringe  ;  6,  funnel  with  tubing 
for  irrigating  kidney  pelves. 


CYSTOSCOPY.  .  371 

through  which  the  examination  can  be  conducted.  It  should  be 
allowed  to  accumulate  till  from  five  to  eight  ounces  are  in  the  blad- 
der. When  the  urine  is  turbid,  as  from  blood  or  pus,  it  should  be 
drawn  by  means  of  a  Nelaton  catheter,  and  the  bladder  should  be 
well  washed  with  a  one-half  per  cent,  carbolic  acid  solution  or  a 
three  per  cent,  boric  acid  solution.  In  thus  washing  the  bladder  it 
is  well  not  to  evacuate  it  wholly  at  any  time,  as  complete  emptying 
encourages  bleeding.  When  the  fluid  finally  comes  away  clear,  five 
ounces  of  the  antiseptic  solution  are  injected  and  are  allowed  to  re- 
main in  the  bladder,  the  catheter  being  removed.  Very  little  blood  is 
sufficient  to  make  the  cystoscopic  examination  unsatisfactory. 

For  satisfactory  examination  the  patient  should  lie  upon  a  table 
with  his  buttocks  slightly  projecting  over  the  edge  and  his  thighs 
widely  separated,  his  feet  resting  on  chairs  or  on  a  shelf  provided  for 
this  purpose.  The  surgeon  sits  on  a  chair  or  stool  between  the 
patient's  legs.  When  ether  is  given,  the  lithotomy  position  is  most 
convenient. 

The  cystoscope,  having  been  tested  as  to  its  lamp  and  the  proper 
working  of  its  visual  apparatus,  is  lubricated  with  glycerin,  and  is  in- 
troduced exactly  as  though  it  were  a  sound,  until  the  elbow  has 
cleared  the  internal  vesical  sphincter.  This  is  denoted  by  the  sudden 
cessation  of  resistance,  by  the  ease  with  which  the  instrurnent  is 
rotated  on  its  long  axis,  and  by  the  position  of  the  shaft,  which  lies 
about  parallel  with  the  long  axis  of  the  body  or  even  pointing  some- 
what downward.  The  light  is  then  turned  on,  and  the  surgeon  pro- 
ceeds to  make  a  systematic  examination  of  every  portion  of  the 
bladder,  avoiding,  as  far  as  practicable,  prolonged  contact  of  the  lamp 
end  of  the  cystoscope  with  the  bladder-walls,  since  there  is  danger  of 
slight  burning  unless  the  lamp  is  supplied  with  a  perforated  hood, 
which  keeps  it  everywhere  surrounded  by  liquid.  In  a  bladder 
moderately  distended  the  lamp  can  be  allowed  to  burn  for  an 
hour  without  materially  changing  the  temperature  of  the  fluid 
about  it. 

The  method  of  conducting  the  examination  must  be  learned  by 
experience ;  rules  giving  the  angles  at  which  the  shaft  of  the  instru- 
ment should  be  held  are  worthless.  The  instrument  can  be  pushed 
in  or  partly  withdrawn,  can  be  partly  or  completely  rotated,  or  can 
be  lateralized  to  a  limited  extent.  By  these  various  motions  the  entire 
healthy  bladder  may  be  seen. 

The  base  of  the  bladder  and  the  trigonum,  as  representing  the 
region  most  prone  to  pathological  alteration,  should  be  inspected 
first ;  after  that  the   posterior   surface,  the  vault,  and  the  anterior 


372  GEN'ITO-UKINARY   DISEASES   AXD    SYPHILIS. 

surface  are  systematically  explored ;  finally,  the  vesical  orifice  of  the 
urethra  is  examined.  Suprapubic  cystoscopy  through  a  canula  is  in- 
dicated when  the  instrument  cannot  be  introduced  through  the  urethra. 

In  obscure  diseases  of  the  bladder  or  kidneys,  Avhen  all  other 
means  have  failed  in  establishing  a  diagnosis,  the  use  of  the  cysto- 
scope  is  indicated,  provided  the  bladder  can  retain  four  ounces  of 
fluid  and  the  urethra  is  pervious  to  a  28  F.  instrument. 

We  can  reasonably  expect  to  determine  by  this  instrument  the 
presence  or  absence  of  tumors,  stones,  foreign  bodies,  diverticula, 
ulcerations,  the  extent  and  character  of  a  cystitis,  the  condition  of  the 
ureteral  orifices,  the  secretory  activity  of  each  kidney,  and  the  source 
of  blood  or  pus  in  the  urine. 

The  cystoscope  should  not  be  used  till  other  means  of  diag- 
nosis, except  exploratory  incision,  have  been  employed  and  the  evi- 
dence derived  from  them  has  been  carefully  weighed.  Its  use,  par- 
ticularly when  there  is  hsematuria  with  sterile  urine,  should  be  preceded 
by  preparation  for  operation  when  it  is  probable  that  this  will  be 
required.  It  should  be  performed  as  soon  as  cystoscopic  examination 
has  positively  demonstrated  that  it  is  indicated. 

The  surgeon  must  first  teach  himself  to  bring  closely  into  view 
every  portion  of  the  inner  surface  of  the  bladder.  The  phantom 
bladder,  cadavera,  and  sexual  neurasthenics,  who  are  often  bene- 
fited by  prolonged  and  painful  manipulation,  offer  the  best  opportu- 
nities for  learning  this  part  of  cystoscopy.  Finally  comes  the  right 
interpretation  of  what  is  seen.  This  requires  a  wide  clinical  expe- 
rience. In  the  hands  of  one  without  experience  the  cystoscope  be- 
comes, in  most  cases,  simply  a  surgical  toy. 

Cystoscopic  Diagnosis. — The  mucosa  of  the  normal  bladder  is 
straw-yellow  in  color,  with  arborescent  vessels  upon  its  surface  and 
slight  but  distinct  trabeculae.  Depression  of  the  shaft  of  the  cystoscope 
and  half  rotation  show  the  base  and  the  trigonum,  suggesting,  says 
Fenwick,  "  a  sandy  shore ;"  at  the  posterior  angles  of  the  trigonum 
are  the  ureteral  orifices,  each  appearing  as  a  depression  or  slit  placed 
in  a  little  ridge  of  mucous  membrane.  At  intervals  of  from  thirty  to 
sixty  seconds,  not  synchronously,  these  ureteral  orifices  gape  and  dis- 
charge a  SAvirl  of  urine.  Crossing  the  upper  portion  of  the  trigonum 
and  forming  its  base  the  interureteral  line  is  characterized  by  a  distinct, 
often  abrupt,  transition  of  color  from  the  straw-yellow  of  the  general 
bladder  cavity  to  the  pink  of  the  trigonum.  This  line  when  traced  later- 
ally leads  to  the  ureteral  orifices.  Occasionally,  in  place  of  the  ridge  there 
is  a  distinct  conical  projection  marking  the  ureteral  orifice,  exhibiting  a 
motion  of  recession  and  protrusion.     Failure  to  find  the  ureters  in  the 


CYSTOSCOPY.  373 

healthy  bladder  is  generally  due  to  incomplete  dilatation  of  this  viscus, 
the  openings  of  these  ducts  being  concealed  in  the  folds  of  the  vesical 
mucosa,  and  appearing  when  these  folds  have  been  obliterated  by  the 
proper  amount  of  vesical  tension.  In  the  vertical  type  of  bladder 
often  seen  with  enlarged  prostate,  the  ureteral  orifices  when  invisible 
may  be  elevated  to  view  by  a  finger  or  staff  in  the  rectum.  The  vesical 
orifice  of  the  urethra  is  examined  by  withdrawing  the  cystoscope  till  the 
greater  part  of  the  field  of  vision  is  occupied  by  a  dark  crimson,  sharply 
marked  fold  strongly  contrasting  with  the  yellow  glare  of  the  bladder 
surface  still  perceptible  through  that  part  of  the  window  which  is  not 
yet  within  the  vesical  neck.  The  crimson  color  is  due  to  transmis- 
sion of  light  through  this  fold.  Its  outlines  are  determined  by  rotating 
the  cystoscope.  In  case  air  has  entered  the  bladder  during  the  prelim- 
inary washing  or  injection,  it  forms  a  round,  movable,  shining  bubble, 
from  the  convex  surface  of  which  the  cystoscopic  lamp  is  reflected. 

It  is  possible  to  mistake  for  a  tumor  the  projection  of  mucous 
membrane  sometimes  seen  about  the  ureteral  orifice.  The  position 
of  the  projection  and  the  intermittent  jets  of  urine 'should  prevent 
such  an  error.  The  rugae,  if  not  sufficiently  distended,  have  been  mis- 
taken for  papillomata ;  a  further  injection  should  make  the  nature  of 
the  projection  sufficiently  clear. 

Blood  deposited  on  the  base  of  the  normal  bladder  may  present 
the  appearance  of  a  severe  subacute  or  chronic  cystitis. 

In  the  acute  or  chronically  inflamed  bladder  the  rugae  may  closely 
simulate  papillomata,  particularly  if  the  inflammation  is  locahzed  in 
one  portion  of  the  bladder,  as  is  sometimes  the  case.  Fenwick  de- 
scribes as  one  of  the  appearances  of  certain  forms  of  chronic  cystitis 
a  polyhedral  or  rectangular  quilting  of  the  bladder,  with  projections 
between  the  seams  of  swollen,  almost  translucent,  mucous  membrane 
presenting  the  appearance  of  a  patch  of  gelatinous  polyps.  A  similar 
condition  at  the  base  may  produce  small  conical  projections,  or  these 
may  be  caused  by  dilated  mucous  glands  or  vesicular  inflammation. 
The  vesicles  formed  are  round,  translucent,  and  small,  from  the  size 
of  a  pin-head  to  that  of  a  shot,  and  are  especially  numerous  over  the 
trigonum. 

Hemorrhage  beneath  the  mucous  membrane  of  the  bladder  causes 
the  formation  of  a  yellow,  partly  translucent,  projecting  tumor,  not 
unlike  papilloma.  The  diagnosis  will  be  founded  on  the  presence 
of  blood-infiltration  and  discoloration  of  the  surrounding  mucous 
membrane. 

Tubercular  cystitis  presents  features  which  may  render  its  diag- 
nosis by  cystoscopic  examination  impossible.     The  lesions,  usually 


374  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

located  on  the  base  or  the  posterior  wall,  are  not  unfrequently  asso- 
ciated with  small  papillomatous  outgrowths.  When  sharply  outlined 
ulcers  develop,  the  diagnosis,  in  the  absence  of  an  acute  or  a  chronic 
cystitis,  is  not  difficult.  When  there  are  general  infiltration  and 
thickening  of  the  surrounding  mucosa,  and  especially  when  there 
is  papillary  outgrowth,  great  care  should  be  exercised  in  forming  an 
opinion  as  to  the  tubercular  nature  of  the  lesions  from  their  appear- 
ance through  the  cystoscope. 

Diverticula,  calculi,  and  foreign  bodies,  such  as  needles  and  por- 
tions of  ligature,  are  readily  detected  by  the  cystoscope.  This  instru- 
ment, however,  finds  its  most  useful  place — 1,  in  the  diagnosis  of 
bladder-tumors  ;  2,  in  determining  the  question  in  cases  of  hgematuria 
and  pyuria  as  to  the  vesical  or  the  renal  origin  of  the  blood  or  pus. 

CystoscopiC  Appearances. — In  acute  cystitis  the  mucous  membrane 
is  intensely  red,  swollen,  and  elevated  (puffy).  Flakes  of  fibrin  may  be 
seen  here  and  there.  Individual  larger  blood-vessels  appear  dilated, 
but  the  fine  reticulum  of  small  vessels  may  be  invisible  in  the  general 
oedema.  The  ureteral  eminences  are  difficult  to  recognize  on  account 
of  the  general  swelhng.  There  may  in  severe  cases  be  membranous 
exudate. 

In  chronic  cystitis  the  inflammation  of  the  vesical  mucous  membrane 
may  be  diffuse  or  localized.  The  diffuse  will  appear  as  general  red- 
ness, always  more  marked  about  the  trigonum  and  orifices  of  the  ureters. 
The  localized  may  show  patches  of  intense  redness,  excoriations,  fis- 
sures, and  linear  ulcers.  In  addition  there  may  be  noted  in  cases  of 
long  standing  vesical  ulceration  areas  of  contraction ,  due  in  part  to 
cicatrices,  in  part  to  muscular  hypertrophy. 

The  localized  patches  of  inflammation  are  observed  in  about  four- 
fifths  of  the  cases  of  cystitis.     (Garceau.) 

There  may  rarely  be  noted  small  red,  shiny  granulations,  such  as 
are  observed  on  other  mucous  membranes.  The  lymphatic  nodules 
may  be  visible  as  small  slightly  elevated  Avhitish  translucent  bodies 
resembling  sago  grains  located  beneath  the  mucous  coat  which  covers 
them.  The  whole  surface  may  present  a  ribbed  appearance  from 
bladder  hypertrophy.  Various  combined  lesions  are  common.  Diffuse 
inflammation,  excoriation,  ulceration,  patches  of  contraction,  and 
hypertrophy  exist  together. 

In  all  forms  of  cystitis  the  severest  lesions  are  located  on  the  pos- 
terior wall  and  trigonum,  owing  to  the  dependent  position  of  those 
regions  and  their  liability  to  traumatism. 

Vesical  ulceration  may  destroy  the  whole  of  the  mucous  membrane 
in  patches,  revealing  a  smooth,  glistening,  pyogenic  membrane,  with 


CYSTOSCOPY.  375 

white  lines  of  scar-tissue  or  granulation  surface.  Ulceration  is  most 
frequently  seen  on  the  posterior  wall  and  within  the  trigonum  at  its 
upper  part. 

Non-tubercular  ulceration  presents  lesions  generally  quite  uniform 
in  contour,  dirty  yellow  in  color,  commonly  about  the  size  of  a  dime, 
and  are  placed  at  or  near  the  ureteral  orifices.  Its  edges  are  slightly 
raised,  undermined,  and  surrounded  by  a  pale  ansemic  zone,  set  in  the 
deeply  injected  mucous  membrane.  This  must  be  distinguished  from 
the  ulcer.  In  contrast  to  the  tubercular  lesion,  they  seldom  extend 
deeply  into  the  underlying  tissue,  though  they  may  manifest  such 
a  tendency.  The  base  is  of  a  yellow  or  yellowish-white  color  and 
usually  smooth,  though  occasionally  necrotic  shreds  may  be  noted  on 
the  surface.  They  are  Ui^ially  multiple  to  the  extent  of  two  or  three 
lesions,  though  they  may  be  single ;  they  occasionally  are  very 
numerous  all  over  the  dependent  portion  of  the  bladder-wall  and  else- 
where, showing  a  tendency  to  coalesce,  resulting  in  great  destruction 
of  the  mucous  surface,  presenting  a  smooth,  glistening,  pyogenic  mem- 
brane with  intermingled  areas  of  scar-tissue  showdng  as  white  lines, 
and  patches  of  redness  where  the  inflamed  mucous  surface  is  still 
intact. 

Traumatic  ulcers  result  from  the  irritation  of  large  or  rough  vesical 
calculi  or  from  the  trauma  of  childbirth. 

Tubercular  Lesions. — In  the  beginning,  i.e.,  before  ulceration  has 
occurred,  miliary  tubercles  appear  as  grayish,  round  elevations  sur- 
rounded by  hypersemic  areas.  These  by  coalescence  and  caseation 
form  the  ulcer.  This  is  generally  superficial,  circular  in  shape,  uneven 
in  contour,  dirty  yellow  in  color,  and  commonly  about  the  size  of  a 
dime.  Its  edges  are  slightly  raised,  undermined,  and  surrounded  by  a 
pale  anaemic  zone,  set  in  the  deeply  injected  mucous  membrane.  This 
must  be  distinguished  from 

Simple  Solitary  Ulcer. — Fenwick  has  described  a  rare  lesion  of  this 
character  and  of  undetermined  cause,  which  in  many  features  is  com- 
parable to  gastric  ulcer.  It  is  solitary,  is  placed  near  the  ureteral 
opening,  its  chief  symptom  is  hemorrhage,  and  it  results  in  the  for- 
mation of  scar-tissue.  The  disease  is  favored  by  traumatism,  such  as 
the  pressure  of  the  child's  head  during  labor,  rough,  unclean  instru- 
mentation, and  vesical  retention. 

Cystoscopic  examination  will  reveal  an  extremely  sensitive,  cir- 
cular, or  slightly  irregular  ulcer  located  on  the  posterior  wall  of  the 
bladder  just  within  (towards  the  median  Hue)  the  ureteral  orifice,  but 
above  the  trigonuni,  about  one  to  one  and  a  half  inches  in  diameter, 
with  slightly  thickened,  elevated  edges,  and  an  uneven,  necrotic  base 


376  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

extending  almost  to  the  muscular  layer.  There  may  occur  deposition 
of  lime  salts  on  its  surface  with  the  production  of  a  secondary  contact 
ulcer  on  the  opposite  (anterior)  wall  of  the  bladder,  and  the  crusts 
may  be  exfoliated  and  voided  in  the  urine.  Cicatrization  is  the  ten- 
dency, and  results  in  the  formation  of  folds  in  the  mucous  membrane, 
resembling  carcinoma,  especially  if  the  folds  become  excoriated  or 
ulcerated.  It  can  be  distinguished  from  tubercular  ulcer  by  the  pres- 
ence or  absence  of  tubercle  bacilli  as  determined  by  examination  of 
the  urine,  pathologic  sections,  and  guinea-pig  inoculation  or  by  the 
tuberculin  test.  The  tubercular  lesion  rarely  becomes  incrusted, 
while  this  is  the  rule  with  the  solitary  ulcer  of  Fenwick. 

The  location  of  the  solitary  simple  lesion  is  always  in  a  certain 
spot  as  noted,  while  the  tubercular  ulcer  may  be  found  in  any  part  of 
the  posterior  surface  of  the  bladder,  and  more  rarely  elsewhere.  The 
sohtary  ulcer  may  be  healed  with  comparative  ease. 

Other  rare  causes  of  vesical  ulceration  are  thrombosis,  syphilis, 
and  trophic  nerve  lesions.  Thrombotic  and  syphilitic  ulceration  are 
absolutely  non-characteristic  in  cystoscopic  appearance. 

Trophic  Ulcers. — Albarran  noted  bladder  lesions  in  five  out  of  six 
cases  of  syringomyeha.  In  three  there  was  latent  retention,  one  of 
which  had  cystitis  with  ulceration.  The  lesions  are  evidently  trophic, 
and  the  ulcers  manifest  a  marked  tendency  to  perforate,  as  actually 
happened  in  one  case  resulting  in  death.  The  contracting  power  of 
the  bladder  is  impaired  early. 

The  loculate  bladder  (Kelly)  is  inflamed,  and  presents  one  or  more 
openings  leading  into  small  saccules  which  undermine  the  bladder- 
wall  for  a  short  distance  beneath  the  muscular  coat.  The  pockets  are 
smooth  from  within,  and  from  their  mouths  may  be  noted  the  escape 
of  retained  mucus  and  pus.  They  are  probably  due  to  a  localized 
defect  of  development  of  the  muscular  wall  leaving  a  weak  spot,  which 
gives  way  to  the  frequent  contraction,  vesical  distention,  and  hyper- 
trophy accompanying  chronic  inflammation. 

They  must  be  distinguished  from  congenital  supernumerary  blad- 
ders and  from  pouches  produced  by  giving  way  of  scar-tissue.  In- 
flammation in  the  loculate  bladder  is  severe  and  extremely  difficult 
to  cure. 

Fistulous  tracts  and  sinuses  may  be  noted  with  the  cystoscope, 
and  extravesical  compression  or  retraction  from  such  causes  as  pelvic 
tumors  or  adhesions  may  produce  alteration  of  contour  of  the  general 
vesical  cavity. 

Cystoscopic  Appearances  in  Diseases  of  the  Upper  Urinary  Tract. — 
The  examination  for  this  purpose  has  for  its  special  object  the  study 


CYSTOSCOPY  377 

of  the  ureteral  orifices.  The  points  to  be  noted  are  :  the  presence  of 
both  openings  ;  their  size,  shape,  and  color ;  the  location  of  lesions 
about  the  orifice  ;  whether  or  not  urine  is  regularly  ejected  at  certain 
periodic  intervals  from  each  ureteral  opening ;  the  relative  and  approx- 
imate amount  of  urine  at  each  ejection  ;  its  appearance,  and, admixture 
with  pus,  blood,  or  gravel.  The  ureteral  eminence  may  be  congeni- 
tally  absent.  Its  orifice  itself  may  be  entirely  closed  by  cicatricial  con- 
traction or  malignant  infiltration.  It  may  be  partially  or  completely 
occluded  by  severe  inflammation  or  obstruction  in  any  part  of  the 
upper  urinary  tract,  or  from  the  same  cause  may  be  placed  in  a 
swollen,  red,  eroded  eminence. 

In  old  men,  the  subjects  of  atheroma,  the  ureteral  orifice  will 
present  the  appearance  of  a  crater-like,  gaping  cleft,  owing  to  loss  of 
muscular  contractility. 

Errors  to  he  avoided  in  Cystoscopy. — The  ureteral  openings  may  lie 
at  different  distances  from  the  urethral  orifice,  and  may  be  almost  hid- 
den in  oedematous  folds  of  mucous  membrane,  so  that  the  instrument 
may  be  pushed  past  them  while  searching.  In  cases  of  doubt  as 
to  whether  a  certain  area  contains  the  ureteral  orifice,  a  finger  in  the 
rectum  or  vagina  may  push  the  suspected  area  into  better  view,  and 
detect  a  flow  of  urine.  If  the  urine  is  invisible  on  account  of  trans- 
parency, it  may  be  colored  by  the  previous  administration  of  methylene 
blue. 

Hypertrophied  and  cedematous  folds  around  the  internal  urethral 
orifice  must  not  be  mistaken  for  tumors  or  polypi.  The  former  are 
usually  multiple  and  opaque. 

A  localized  trabeculation  caused  by  the  irritation  of  the  beak  of  the 
instrument  must  not  be  mistaken  for  the  constant  uniform  true  tra- 
beculation over  the  whole  of  the  fundus  and  vertex. 

Cystoscopic  burns  must  not  be  mistaken  for  true  ulcers.  Incrusta- 
tions over  tumors  must  not  be  mistaken  for  calculi  nor  varicose  nod- 
ules for  tumors. 

Cystoscopic  Diagnosis  of  Vesical  Tumors. — It  must  not  be  forgotten 
that  even  by  the  expert  the  interpretation  of  bladder-pictures  has 
been  misleading.  Tumors  have  been  diagnosed  by  the  cystoscope 
which  could  not  be  found  on  opening  the  bladder.  Per  contra., 
tumors  which  were  not  seen  have  been  found  and  removed  by 
suprapubic  cystotomy. 

The  position  of  the  tumor,  particularly  in  regard  to  its  com- 
pressing effect  upon  one  or  both  ureters,  should  be  carefully  noted. 
In  case  of  such  pressure  the  intermittent  forcible  jet  from  the  ureter 
is  not  seen. 


378  GENITO-UPvINAEY   DISEASES   AJnTD   SYPHILIS. 

The  size  of  the  tumor  is  not  easily  determined,  since  this,  as  seen 
through  the  cystoscope,  varies  in  accordance  with  the  distance  of  the 
window  from  the  object  inspected.  Practice  with  objects  of  known 
dimensions  will  enable  the  operator  to  form  a  fairly  good  estimate. 

The  shape  of  the  tumor,  the  presence  or  absence  of  a  pedicle,  and 
the  number  of  tumors,  should  be  investigated.  Information  gained  by 
direct  inspection  is  not  only  valuable  from  a  diagnostic  stand-point, 
but  may  determine  the  manner  of  subsequent  surgical  intervention. 

Positive  determination  as  to  the  benign  or  malignant  nature  of 
a  growth  is  often  impossible,  since,  even  when  the  latter  is  removed 
by  cystotomy,  it  may  happen  that  this  question  cannot  be  settled  till 
a  microscopic  examination  has  been  made.  Distinctly  pedicled 
growths,  particularly  those  presenting  long,  regular,  undulating 
fringes,  are  usually  benign.  (Fig.  124,  C  and  D.)  Such  growths 
about  the  urethral  orifice  may  be  detected  by  the  use  of  the  irri- 
gating cystoscope,  the  injected  stream  sweeping  the  fringes  away 
from  the  window  and  the  light,  which  they  sometimes  completely 
cover. 

Sessile  cauHflower  growths  (Fig.  124,  B)  or  irregular,  ragged  papil- 
lary projections  from  an  ulcerated  or  indurated  surface  are  indicative 
of  malignancy.  A  locahzed  induration  of  the  bladder-wall,  the  form 
in  which  malignant  growth  often  appears,  may  sometimes  be  detected 
by  distending  the  viscus  to  its  full  capacity.  The  fluid  is  then  allowed 
to  escape,  the  suspected  induration  being  kept  under  observation. 
Usually  such  infiltration  can  best  be  found  by  digital  examination. 
A  diagnosis  between  carcinoma  and  sarcoma  cannot  be  made. 

The  backward  projection  of  an  hypertrophied  prostate  may  suggest 
an  extension  backward  of  a  cancerous  infiltration  of  this  gland.  Fen- 
wick  states  that  in  malignant  extension  the  growth  breaks  through 
towards  the  middle  or  the  base  of  the  trigonum,  whilst  the  intra- 
vesical outgrowth  of  enlarged  prostate  is  found  near  the  vesical  orifice 
of  the  urethra.  • 

The  determination  of  the  vesical  or  renal  origin  of  blood  or  pus  in 
the  urine  must  at  times  depend  absolutely  upon  cystoscopic  findings. 
Any  of  the  modern  cystoscopes,  but  particularly  those  designed  for 
catheterizing  the  ureters,  bring  the  orifices  of  these  channels  clearly 
into  view.  If  the  blood  or  pus  is  discharged  freely,  the  irrigating  cys- 
toscope must  be  used,  otherwise  the  fluid  in  the  bladder  becomes 
opaque  so  quickly  that  nothing  can  be  seen.  By  subjecting  each  ure- 
teral orifice  to  careful  scrutiny,  the  swirls  of  blood-stained,  or  in  case 
of  pus  opaque  white,  fluid  ejected  into  the  comparatively  clear  blad- 
der-contents will  make  possible  a  positive  diagnosis. 


Fig.  124. 


Median  obstruction  in  prostatic  hypertrophy. 

(After  Nit7.e.) 


Showing  a  widespread  malignant  tumor  from 
the  prostate.     (After  Nitze.) 


Villous  tumor  attached  to  the  bladder-wall.    (After  Nitze.) 


Shows  the  stump  of  a  villous  tumor  which 
has  sloughed  off.  The  stump  is  now  oove.red 
over.     (After  Nitze.) 


An  air-bubble  which  was  carried  into  the 
bladder  by  a  catheter.     (After  Nitze.) 


Fio.  125. 


A  oystoscopic  picture  of  the  normal  blad- 
der. The  window  of  the  instrument  is  in  the 
deep  urethra.  The  lower  half  of  the  picture 
shows  a  translucent  fold  of  the  internal  ure- 
thral orifice  with  its  sharp  edge  directed 
towards  the  upper  part  which  corresponds 
with  the  anterior  wall.      (After  Nitze.) 


Ramifying  vessels  on  the  bladder-wall. 
(After  Nitze.) 


The  ureteral  orifice  on  a  well-developed  ure- 
teral eminence.     (After  Nitze.) 


The  ureteral  papilla  is  wanting.    The  orifice 
appears  as  a  simple  slit      (After  Nitze.) 


The  ureteral  papilla  immediately  before 
evacuation  of  the  urine.  The  region  sur- 
rounding the  orifice  is  raised  into  a  button- 
shaped  x>rojection.     (After  Nitze.) 


Well  developed  ureteral  papilla.    The  orifice 
appears  as  a  shallow  groove.    (After  Nitze.) 


Fig.  126. 


Pictures  of  the  bladder-wall  and  internal  urethral  orifice  in  cases  of  prostatic  hypertrophy. 

(After  Nitze.) 


Fig.  127. 


Right  ureteral  orifice  immediately  before  contraction  of  the  ureter  for  the 
purpose  of  emptying  itself.  The  bladder-wall  shows  diffuse  cystitis.  (After 
Casper.) 


Enormous  left  ureteral  orifice  in  a  case  of  pyelitis  with  cystitis.   (After  Casper.) 


Left  ureteral  orifice.    The  upper  part  of  the  field  of  vision  shows  cystitis,  the 
lower  portion  is  comparatively  normal.    (After  Casper.) 


Left  ureteral  orifice  with  diffuse  cystitis.  The  bladder-wall  appears 
dimmed,  no  vessels  are  perceptible ;  but  an  abnormal  redness  covers  almost 
the  entire  field  of  vision,  only  a  small  area  appears  to  be  comparatively  little 
involved.    (After  Casper.) 


EXAMINATION   OJF  UKINE  FKOM  EACH  KIDNEY  SEPAliATELY.     379 

Examination  of  Urine  from  each  Kidney  Separately. — A 

rough  estimate  of  the  presence,  amount,  regularity,  and  certain  other 
general  characteristics  of  the  excreting  and  conducting  power  of  the 
upper  urinary  tract  may  often  be  secured  from  observation  of  the 
ejection  of  urine  from  the  ureteral  orifices  during  cystoscopy.  Such 
observations  are  facilitated  by  coloring  the  urine  by  administering  such 
drugs  as  methylene  blue  or  indigo  carmine  a  half-hour  before  cysto- 
scopy. 

Massage  of  the  Kidneys. — The  patient  is  kept  in  bed  for  a  few 
hours  prior  to  examination.  A  specimen  of  urine  should  be  saved  for 
comparison.  The  bladder  is  irrigated  with  a  mild  antiseptic  solution. 
The  kidney  of  one  side  is  then  squeezed  for  several  minutes  to  express 
its  contents.  The  urine  is  drawn  (the  instrument  may  be  left  in  during 
the  procedure)  and  the  specimen  set  aside.  The  opposite  kidney  is 
then  massaged  in  the  same  way  and  this  specimen  secured. 

Ureteral  Catheterization. — The  purposes  of  this  procedure  are : 
(1)  To  determine  whether  both  kidneys  and  ureters  exist  and  are 
physiologically  active.  (2)  To  secure  the  urine  from  each  kidney  sep- 
arately, in  order  to  determine  whether  or  not  such  products  as  pus, 
blood,  epithelium,  tuberculous  material,  bacteria,  and  calculous  crystals 
have  their  origin  in  the  upper  or  lower  urinary  tract,  and  if  from  the 
kidney  or  ureter,  in  which  of  these  organs ;  and  to  determine  the 
secretory  activity  of  each  kidney.  (3)  To  recognize  and  locate  such 
obstructive  conditions  as  torsion  and  bending  of  the  ureters,  valvular 
folds,  calculi,  stricture,  ureteral  fistulae,  etc.  (4)  To  determine  in  cer- 
tain cases  the  character  of  the  operation  advisable.  (5)  To  remove 
obstructions  and  drain  the  ureters  and  kidneys.  (6)  To  medicate  and 
irrigate  these  organs. 

Many  modern  instruments  are  efficient,  among  them  being  those 
of  Eisner,  Cabot,  and  Tilden  Brpwn ;  Kelly's  straight  tubes  are  gen- 
erally applicable  in  the  female.  The  operation  in  males  often  requires 
ether  ansesthesia,  always  the  greatest  gentleness,  exposes  the  patient 
to  the  dangers  of  traumatism  to  the  bladder  and  ureters,  and  the 
risks  of  carrying  infection  from  the  bladder  upward. 

The  preparation  and  technique  of  ureteral  catheterization  is  iden- 
tical with  that  of  cystoscopy  up  to  the  point  of  introduction  of  the 
ureteral  catheters.  The  aseptic  technique  should,  if  possible,  be  even 
more  rigid.  The  ureteral  orifices  are  often  difficult  to  find.  The 
interureteral  bar  is  the  most  important  landmark ;  in  the  vertical  type 
of  bladder  a  staff  in  the  rectum  may  elevate  them  to  view.  The 
administration  of  methylene  blue  before  operation  will  color  the  urine 
and  render  it  visible  when   ejected  from  the  ureteral   orifice.     The 


380 


GENITO-URINARY   DISEASES   AND   SYPHILIS. 


Fig.  128. 


position  of  the  lens  should  be  as  near  as  possible  to  the  ureteral 
orifice.  The  catheter,  having  been  previously  sterilized  and  tested  to 
make  sure,  that  its  lumen  is  free,  is  made  to  enter  the  ureteral  orifice, 
and  is  passed  upward  by  a  rotary  motion  for  a  distance  of  about  five 
centimetres  (two  to  two  and  one-half  inches)  if  catheterization  is  the 
only  purpose.  For  exploring  and  irrigating  the  ureters  and  renal  pelvis 
it  may  be  carried  on  to  the  kidney  pelvis.  With  each  catheter  placed 
in  the  appropriate  ureter,  the  cystoscope  may  be  carefully  withdrawn 
so  as  not  to  disturb  the  catheters,  and  the  external  ends  tied  in  place 
in  the  same  manner  that  filiform  bougies  are  secured;  or  the  instru- 
ment may  be  left  in  situ  and 
held  for  the  one-half  to  one 
hour  necessary  for  enough 
urine  to  accumulate  in  the 
glass  tube  or  bottle  into  which 
each  catheter  empties.  The 
operation  should  be  per- 
formed at  the  time  of  day 
when  secretion  is  free,  and 
it  is  well  to  administer  a  large 
draught  of  water  a  couple  of 
hours  before.  It  often  re- 
quires several  minutes  for 
urine  to  flow  even  when  the 
instruments  are  positively  in 
the  ureters,  and  then  it  ap- 
pears in  drops  at  the  rate 
of  about  five-tenths  a  cubic 
centimetre  (seven  to  eight 
minims)  per  minute  from 
each  normal  kidney.  Grund 
has  noted  complete  anuria  lasting  over  half  an  hour,  incident  to  the 
reflex  set  up  by  cystoscopy,  and  warns  against  accepting  the  results  of 
such  examination,  unless  reflex  anuria  can  be  excluded.  Salol, boric  acid, 
and  urotropin  are  always  indicated  after  intravesical  instrumentation. 
Ureteral  catheterization  in  women  presents  much  less  difficulty  than 
in  men.  The  technique  is  similar.  Kelly  advises  the  knee-chest  posi- 
tion, Webster  the  exaggerated  Trendelenburg. 

The  catheterizing  female  cystoscope  may  be  employed,  or  the 
straight  urethral  tube,  the  light  being  reflected  either  by  means  of  a 
head  mirror,  or  by  a  small  electric  light  fitted  in  the  tube. 

Segregation  of  Urine. — This  has  for  its  sole  purpose  to  secure  the 


Cathelin's  urine  separator. 


EXAMINATION  OF  URINE  FROM  EACH  KIDNEY  SEPARATELY.    381 

urine  separately  from  each  kidney.  Among  the  instrmnents  employed 
are  those  of  Harris,  Luys,  and  Cathelin.  The  latter  is  most  efficient. 
Cathelin's  vesical  segregator  consists  of  a  cylindrical  tube  (calibre  25  F.), 
now  made  of  various  sizes,  shaped  at  one  end  like  a  short  beaked 
catheter.  The  shaft  is  divided  into  three  compartments  :  The  central 
carrying  a  chain  attached  at  the  handle  to  a  wheel  and  at  its  vesical 
end  to  a  thin,  soft,  rubber  membrane,  set  with  a  delicate  steel  spring ; 
each  lateral  compartment  carrying  a  catheter.  The  intravesical  end 
of  the  instrument  is  so  grooved  that  when  the  membrane  is  projected 
within  the  bladder,  it  will  maintain  a  vertical  position.     It  thus  divides 

Fig.  129. 


r'  ijbK^^'  •  -'  "»• 


Cathelin's  urine  separator. 


the  bladder  and  posterior  urethra  into  two  entirely  separate  lateral 
chambers  (Fig.  128),  each  chamber  receiving  urine  only  from  its 
corresponding  kidney.  The  instrument  may  be  sterilized, — each  part 
separately, — and  when  mounted  must  be  lubricated.  The  patient  is 
placed  in  the  horizontal  posture  on  either  a  table  or  a  mattress  ren- 
dered firm  by  a  board  to  prevent  sagging,  and  the  bladder  irrigated 
with  boric  acid  or  adrenalin  solution  until  the  fluid  returns  clear. 
The  vesical  capacity  should  be  determined  by  slowly  injecting  fluid 
until  a  distinct  desire  to  urinate  is  noted.  This  fluid  is  now  withdrawn, 
and  a  definite  amount  (two  or  three  ounces)  of  fresh  clean  solution 
injected  and  allowed  to  remain  to  start  siphonage,  and  to  make  sure 
that  the  lumen  of  each  catheter  is  open.     The  instrument  is  inserted 


382  GENITO-UEINAEY   DISEASES   AND    SYPHILIS. 

exactly  as  a  sound  is  passed,  and  after  the  beak  enters  the  bladder  it 
is  gently  withdrawn  forward  until  it  is  felt  to  impinge  tightly  against 
the  symphysis  pubis.  By  means  of  an  arrangement  at  the  outer  end, 
the  diaphragm  is  opened  ;  the  flexible  septum  adapting  itself  accurately 
to  the  contour  of  the  bladder.  The  catheters  are  now  adjusted  and 
the  total,  or  perhaps  a  little  more  than  the  measured  quantity  of  fluid 
which  was  allowed  to  remain,  is  withdrawn,  proving  the  catheters  to 
be  properly  placed,  their  lumens  clear,  and  both  chambers  empty. 
The  outer  end  of  the  shaft  is  supported  on  a  rest  in  such  a  position  as 
to  allow  good  siphonage  into  the  small  flasks  into  which  each  catheter 
empties.  (Fig.  129.)  From  ten  to  thirty-five  minutes  are  required 
to  secure  enough  urine  for  examination.  The  instrument  after  being 
properly  adjusted  should  not  be  disturbed.  If,  however,  the  catheters 
become  clogged,  they  may  be  opened  by  gently  injecting  several  drops 
of  water  through.  Great  care  must  be  exercised  not  to  set  up  even 
the  smallest  amount  of  bleeding  by  the  instrument  or  blood  "^vill 
appear  in  both  urines.  The  membrane  must  be  accurately  adapted 
to  the  inner  surface  of  the  bladder.  If  not  tight  enough  the  urine  will 
be  mixed,  if  too  tight  pain  even  to  the  extent  of  tenesmus  will  be  pro- 
duced. The  same  effect  will  be  produced  if  the  ends  of  the  catheter 
are  allowed  to  irritate  the  vesical  mucous  membrane,  and  if  their  ends 
are  above  the  level  of  the  fluid,  the  urine  will  fail  to  flow.  The 
method  is  inapplicable  in  certain  cases  with  enormously  hypertrophied 
prostate,  or  in  any  condition  producing  marked  irregularities  in  contour 
of  the  vesical  wall,  and  while  it  produces  little  pain  in  a  non-sensitive 
bladder  it  is  intolerable  in  acute  cystitis.  As  to  its  efficiency  in  properly 
selected  cases,  there  is  abundant  evidence.  It  is  not  sufficiently  accurate 
for  a  bacteriological  differentiation  of  the  urine. 

Determination  of  Renal  Capability. — The  questions  to  be 
solved  are :  (1)  What  is  the  excreting  power  of  the  kidneys  ?  (2) 
What  is  the  probable  chance  that  the  remaining  kidney  may  accom- 
plish physiological  compensation  in  case  its  fellow  must  be  removed  ? 

To  solve  these  questions  involves  a  study  of  the  combined  func- 
tional power  of  both  kidneys  together,  and  in  case  of  contemplated 
radical  treatment,  of  each  organ  separately.  The  chief  physical  func- 
tion of  the  kidneys  is  permeability.  The  most  conspicuous  vital 
function  of  these  organs  is  to  excrete  from  the  blood  the  end  products 
of  metabolism. 

Various  tests  of  these  functions  and  of  the  total  renal  power  have 
been  applied  with  more  or  less  practical  results  ;  among  which  are 
the  simple ,  dilution  test ;  the  indigo  carmine  test ;  the  phloridzin  test ; 
and  cryoscopy  of  the  blood  and  urine. 


KENAL    CAPABILITY.  383 

The  Dilution  Test  of  Renal  Function. — This  has  for  its  purpose 
determination  of  the  permeabihty  and  excretory  power  of  the  renal 
structures  to  water.  The  points  considered  to  be  of  value  are  :  (1) 
Delay  in  the  appearance  of  increased  excretion  after  the  ingestion  of 
large  quantities  of  water.  (2)  Relative  delay  and  difference  in  the 
amount  excreted  by  each  kidney  separately.  (3)  Relative  proportion 
of  molecular  concentration  in  the  urine  from  each  kidney  separately 
as  determined  by  cryoscopy.  The  patient  after  emptying  the  bladder 
is  given  to  drink  a  large  quantity  of  water  at  one  time  ;  and  for  sev- 
eral hours  following,  the  urine,  as  secured  from  each  kidney  separately, 
is  measured  and  examined.  This  necessitates  ureteral  catheteriza- 
tion every  half-hour  or  every  hour,  or  the  presence  in  the  bladder  of 
the  divisor  continuously ;  and  must  in  every  case  be  governed  by  a 
contcol  test. 

Strous  demonstrated  by  this  method  insufficiency  long  before  it 
could  be  detected  by  any  other  means. 

The  Indigo  Carmine  Test  of.  Renal  Capability  is  based  on  the 
power  of  the  renal  structures  to  eliminate  this  coloring  matter  after 
subcutaneous  administration.  Water  is  withheld  from  the  patient  for 
some  hours.  Twenty  c.c.  sterile  0.4  per  cent,  solution  in  normal 
salt,  of  indigo  carmine,  is  injected  subcutaneously,  after  cleansing 
and  evacuating  the  bladder.  If  the  kidneys  be  normal  the  urine  is 
colored  within  ten  minutes.  Delayed  and  prolonged  ehmination  point 
to  impaired  renal  permeability. 

The  Phloridzin  Test  has  for  its  basis  the  power  of  normal  kidneys 
to  eliminate  sugar  within  a  certain  time  after  the  subcutaneous  admin- 
istration of  phloridzin.  If  sugar  does  not  appear  within  thirty  minutes 
this  shows  that  both  kidneys  are  diseased. 

After  emptying  the  bladder  five  milligrammes  of  a  sterlized  prepa- 
ration of  phloridzin  with  an  equal  quantity  of  sodium  carbonate  (or  one 
cubic  centimeter  of  a  freshly  boiled  one  per  cent,  solution,  Kapsammer), 
are  administered  subcutaneously.  Normally,  sugar  appears  in  the  urine 
in  fifteen  minutes.  Within  a  half-hour  after  administration,  the  nor- 
mal urine  should  contain  forty-five  one  hundredths  per  cent,  sugar. 
The  sugar  should  be  absent  at  the  end  of  four  hours.  In  serious  renal 
disease  the  appearance  of  the  sugar  is  delayed,  and  elimination  is  pro- 
longed, markedly  reduced  in  quantity  or  absent.  Quantities  of  three- 
tenths  per  cent,  or  less  within  the  first  half-hour  indicate  insufficiency. 
The  drug  is  harmless.  Israel  reports  cases  in  which  sugar  did  not 
appear  though  the  kidneys  were  normal. 

Cryoscopy. — The  freezing-point  of  blood  and  urine  is  dependent  on 


334  GElSriTO-URINAKY   DISEASES   AND   SYPHILIS. 

molecular  concentration.  This  molecular  content  is  maintained  at 
a  more  or  less  constant  point  largely  through  the  selective  and  elimi- 
native  functions  of  the  kidneys.  Upon  this  basis  has  been  suggested 
the  freezing  test  as  an  index  to  renal  capability. 

The  urine  to  be  examined  for  unilateral  renal  capability  must  be 
obtained  from  each  kidney  separately  ;  for  determining  total  insuffi- 
ciency in  bilateral  kidney  disease  mth  a  healthy  bladder,  the  bladder 
urine  may  be  used.  The  blood  may  be  obtained  from  one  of  the 
superficial  veins  at  the  elbow,  by  means  of  a  small  trocar.  The 
amount  of  either  fluid  required  is  from  ten  to  twenty  cubic  centimetres 
(two  and  five-tenths  to  five  drachms).  It  must  always  be  kept  in  a 
perfectly  clean  vial  or  test-tube,  and  unless  examined  fresh  should  be 
kept  in  a  refrigerator  to  prevent  decomposition. 

Kiimmel  from  a  study  of  two  hundred  and  fifty  cases  determines 
that,  in  healthy  individuals  free  from  kidney  disease,  the  freezing-point 
of  the  blood  is  constantly  between  0.55°  and  0.57°  below  zero,  0.56° 
C.  being  taken  as  the  normal.  That  of  the  urine  is  quite  variable  be- 
tween 1.2°  and  2.3°  C.  below  zero.  He  concludes  that  a  freezing-point 
for  the  blood  lower  than  0.58°  or  for  the  urine  lower  than  1.0°  below 
zero  is  indicative  of  renal  insufficiency. 

The  technique  of  these  so-called  accurate  tests  is  intricate,  and 
subject  to  many  sources  of  error,  even  in  skilled  hands.  The  indigo 
carmine  test  gives  greatest  promise  of  Usefulness. 

To  determine  functional  power  of  one  kidney  the  urine  to  be 
examined  must  be  obtained  by  catheterization  of  the  ureter.  If 
catheterization  is  impossible,  and  nephrectomy  is  contemplated,  both 
kidneys  should  be  exposed  and  examined  before  either  is  removed. 

All  food  necessitating  extra  work  on  the  part  of  the  kidney  must  be 
excluded ;  in  many  cases  the  diet  should  be  limited  to  milk.  Rest  in 
bed,  free  purgation,  a  warm  room  free  from  draughts,  in  some  cases 
diaphoresis  by  drugs  and  occasionally  hot  packs  or  vapor  baths  are 
demanded.  Cardiac  and  vascular  tonics,  particularly  digitalis,  and  for 
its  relaxing  effect,  nitroglycerine  are  useful.  The  urine  must  be  ren- 
dered bland,  all  sources  of  irritation  and  obstruction  removed,  and 
perfect  drainage  of  these  organs  maintained.  It  has  been  many  times 
conclusively  demonstrated  that  thorough  bladder-drainage  by  cath- 
eter is  one  of  the  most  potent  factors  and  often  sufficient  in  itself  to 
restore  impaired  renal  function.  Nitrous  oxide  anaesthesia  when  prac- 
ticable should  be  employed  during  operative  procedures  in  preference 
to  ether  and  chloroform  ;  extra  precautions  against  shock  should  be 
taken,  entero-  and  hypo-dermoclysis  of  hot  normal  salt  solution  are 
valuable.  If  both  kidneys  are  the  seat  of  extensive  disease,  double 
nephrotomy  is  preferable  to  single  nephrectomy  combined  with  ne- 


RENAL   CAPABILITY.  385 

phrotomy.  If  the  disease  is  unilateral  and  nephrectomy  is  indicated, 
this  should  be  performed  at  once,  a  preliminary  nephrotomy  is  indi- 
cated only  when  the  patient's  condition  is  such  as  to  make  total 
removal  of  the  kidney  unjustifiable.  Primary  nephrectomy  with  the 
opposite  organ  already  crippled  often  results  fatally,  the  sudden  extra 
work  thrown  on  the  remaining  organ  resulting  in  total  cessation  of 
function. 

Surgical  Treatment  of  Nephritis. — The  signs  of  inflamma- 
tion of  the  kidney  having  for  their  basis  some  localized  etiologic  factor, 
such  as  stone,  abscess,  renal  mobility,  etc.,  present  certain  indications 
for  surgical  intervention  and  are  discussed  in  their  appropriate  places. 
True  bilateral  Bright's  disease,  dependent  upon  extra  renal  systemic 
causes,  is  accompanied  by  the  evolution  of  a  different  morbid  process 
both  m  the  kidneys  and  in  the  structures  throughout  the  body,  par- 
ticularly in  the  circulatory  apparatus. 

The  physiologic  effect  of  such  morbid  changes  is  renal  insufficiency. 
Clinically,  this  is  marked  by  auto-toxaemia,  hydraemia,  general  anasarca, 
ascites,  hydrothorax,  high  circulatory  tension  with  cardiac  hypertrophy, 
finally,  insufficient  compensation  and  myocardial  degeneration,  ending 
with  gradual  fall  of  blood-pressure  to  circulatory  failure. 

The  immediate  anatomical  effects  of  renal  decapsulation  as  proposed 
by  Edebohls  in  the  treatment  of  nephritis,  are  the  release  of  excessive 
intra-capsular  tension,  and  more  or  less  laceration  of  the  renal  cortex. 
In  cases  of  acute  diffuse  nephritis,  the  large  white  kidney  of  chronic 
parenchymatous  disease,  and  in  the  engorgement  accompanying  acute 
exacerbations  in  the  course  of  any  form  of  chronic  nephritis,  the  organ 
immediately  expands  upon  incising  the  capsule. 

The  remote  effects  have  been  conclusively  demonstrated  clinically, 
experimentally,  and  by  a  few  autopsies  in  the  human  subject.  A  new 
connective-tissue  capsule  is  formed  from  the  connective-tissue  cells 
of  the  intertubular  structure  and  surrounding  cellular  proliferation. 
This  contracts,  becomes  dense,  and  intimately  related  to  the  renal 
cortex.  It  is  in  a  large  measure  devoid  of  blood-vessels,  and  shows 
no  intercommunicating  anastomotic  branches.  The  organ  becomes 
firmly  fixed,  and  the  clinical  phenomena  of  a  rapidly  progressive,  con- 
tracted, shrunken  kidney  are  instituted.  Such  phenomena  become 
apparent  generally  within  a  few  months.  About  seventy-five  per  cent, 
of  the  remote  mortality  is  due  to  diffuse  nephritis. 

Puncture  of  the  kidney  and  capsular  incisions  produce  a  similar 
effect  in  reheving  tension,  though  less  marked  than  complete  decapsu- 
lation.    The  damage  to  the  cortex  is  less  severe,  and  the  newly  formed 


386  GENITO-UPvINARY   DISEASES   AND   SYPHILIS. 

cicatricial  capsule  less  regular  in  structure.     In  progressive   uraemia 
this  form  of  local  depletion  is  distinctly  indicated. 

The  organ  may  be  decapsulated  rapidly  under  nitrous  oxide,  light 
ether,  or  chloroform  anaesthesia,  in  some  cases  with  the  aid  of  local 
anaesthesia  by  the  infiltration  method.  The  technique  is  that  of 
denudation.  (See  page  535.)  Ante-  and  post-operative  treatment 
must  be  rigid  to  the  minutest  detail,  guarding  particularly  the  cir- 
culatory apparatus  and  against  pulmonary  complications,  notably 
oedema.  The  most  rigid  aseptic  technique  must  be  employed  and 
the  water  (urine)  soaked  dressings  must  be  changed  sufficiently  often 
to  maintain  a  dry  wound. 


CHAPTER   X. 

INJURIES    AND    DISEASES    OF    THE    BLADDER. 

Anatomy. — The  bladder,  when  normally  distended,  holds  about 
one  pint  of  fluid.  Provided  its  walls  are  healthy,  the  urine  may  be 
retained  without  risk  of  injury  till  twice  that  quantity  has  accumu- 
lated. When  from  chronic  obstruction  there  is  constant,  slowly  in- 
creasing intravesical  tension,  the  bladder  may  become  greatly  dis- 
tended, retaining  over  a  gallon  of  urine.  When  empty,  or  moderately 
distended,  the  bladder  hes  within  the  pelvis,  between  the  posterior 
surface  of  the  pubic  symphysis  and  the  rectum.  As  it  fills,  its  upper 
portion  rises  from  the  pelvis  and  can  be  felt  on  abdominal  palpation, 
since  it  tilts  forward  and  is  closely  applied  to  the  belly-wall.  As  ten- 
sion increases,  the  upper  posterior  wall  bulges  upward,  and  may  be 
felt  even  above  the  umbilicus. 

The  base  or  fundus  of  the  bladder,  that  portion  lying  between  the 
line  of  reflection  of  the  vesico-rectal  peritoneal  fold  and  the  vesical 
orifice,  is  wider  and  more  capacious  than  the  summit.  The  vesical 
orifice,  the  lowest  portion  of  the  bladder  in  the  erect  position,  is  placed 
about  one  and  a  quarter  inches  behind  and  slightly  below  the  middle 
of  the  pubic  symphysis  ;  in  children,  this  orifice  is  on  a  level  with  the 
upper  border  of  the  symphysis,  the  bladder  in  them  lying  much  higher 
in  the  abdomen. 

The  upper  portion  of  the  bladder  is  freely  movable ;  its  base  is 
more  or  less  fixed.  It  is  held  in  place  by  the  recto-vesical  fascia,  by 
the  intimate  muscular  and  fibrous  attachments  to  the  prostate,  by 
the  urachus  and  the  ol)literated  hypogastric  arteries,  by  its  vascular 
connections,  and  finally  by  ligaments  derived  mainly  from  the  reflec- 
tions of  the  pelvic  fascia  (true  hgaments)  and  from  the  peritoneum 
(false  ligaments). 

The  urachus,  a  fibro-muscular  cord,  and  the  obliterated  hypogas- 
tric arteries  pass  from  the  summit  of  the  bladder  to  the  umbilicus. 
The  expansions  of  the  pelvic  fascia  hold  the  neck  and  base  of  the 
bladder  in  position.  The  anterior  or  pubo-prostatic  ligaments  from 
either  side  of  the  lower  portion  of  the  pubic  symphysis  fix  the  pros- 
tate gland  and  the  anterior  part  of  the  bladder  neck  ;  the  lateral  liga- 
ments embrace  the  prostate  and  the  lateral  border  of  the  bladder 
base.     The  false  ligaments  or  peritoneal  folds  are  the  superior,  cover- 

387 


388 


GENITO-UKINAKY   DISEASES   AND  SYPHILIS. 


ing  the  urachus  and  the  obliterated  hypogastric  arteries  from  the  um- 
bilicus to  the  vesical  apex,  the  lateral,  reflected  from  the  iliac  fossge 
to  the  bladder  sides,  and  the  posterior,  containing  the  ureters  and 
hypogastric  arteries  and  bounding  the  recto-vesical  fold. 

Peritoneal  Covering  of  the  Bladder. — The  peritoneal  covering  of 
the  urachus  and  the  obliterated  hypogastric  arteries  passes  directly  to 
the  bladder,  investing  its  posterior  surfaces  from  the  apex  to  the  pos- 
terior extremities  of  the  seminal  vesicles  and  the  vesical  extremities  of 

Fig.  130. 


Side  view  of  pelvic  viscera. 


the  ureters.  It  is  continued  laterally  to  the  position  of  the  obliterated 
hypogastric  arteries,  passing  backward  as  it  descends  to  the  recto- 
vesical cul-de-sac,  and  covering  a  portion  of  the  vas  deferens.  Pos- 
teriorly, the  peritoneum  is  reflected  from  the  bladder  to  the  rectum, 
forming  the  recto-vesical  pouch.  This  pouch  is  usually  more  than 
three  and  less  than  four  inches  from  the  anus  ;  exceptionally,  the  vesi- 
cal peritoneum  may  descend  as  far  as  the  prostate,  and  would  then 
be  less  than  two  inches  from  the  anal  orifice. 


INJUEIES   AND   DISEASES   OF    THE    BLADDER.  389 

When  the  bladder  is  empty  the  peritoneum  lining  the  anterior 
belly-wall  descends  as  far  as  the  upper  border  of  the  pubis,  and  is 
reflected  from  this  level  to  the  vesical  apex.  As  the  bladder  becomes 
distended  this  peritoneal  reflection  is  lifted  upward,  and  the  anterior 
vesical  wall  becomes  accessible  to  operation  by  suprapubic  incision 
without  danger  of  entering  the  peritoneal  cavity.  (Fig.  130.)  When 
the  bladder  is  moderately  distended  and  is  further  elevated  by  rectal 
distention,  the  peritoneal  reflection  may  be  raised  two  inches  above 
the  upper  border  of  the  symphysis. 

Exceptionally  the  parietal  peritoneum  is  adherent  to  the  symphysis. 
In  this  case  a  suprapubic  cut  must  necessarily  open  the  general  ab- 
dominal cavity.  There  is  no  means  of  determining  the  presence  of 
such  an  anomalous  condition  before  operation :  hence  the  danger 
always  possible  in  suprapubic  puncture  or  aspiration. 

Structure  of  the  Bladder. — The  mucous  membrane  of  the  blad- 
der is  made  up  of  flat  epithehum  based  upon  deep  layers  of  cylin- 
drical cells.  It  is  of  a  yellowish  color,  exhibiting  plications  which 
disappear  on  distention  of  this  viscus.  The  submucous  fibrous  tis- 
sue contains  elastic  fibres,  and  by  its  loose  attachment  to  the  under- 
lying muscles  enables  the  mucous  membrane  to  accommodate  itself  to 
the  changes  in  dimensions  to  which  the  bladder  is  constantly  subject. 
In  the  trigonum  the  mucous  membrane  is  applied  directly  to  the  sub- 
jacent structure,  and  slight  papillary  outgrowths  are  sometimes  seen ; 
exceptionally  rudimentary  glands  are  found. 

The  muscular  walls  of  the  bladder  are  arranged  in  three  layers. 
The  outer  longitudinal  layer  contributes  fibres  to  the  formation  of 
the  anterior  vesical  ligaments.  Through  or  between  these  musculo- 
tendinous fasciculi  pass  the  anterior  vesical  veins  to  join  the  plexus 
of  Santorini.  The  middle  layer  is  composed  of  circular  fibres  com- 
pletely covering  in  the  bladder.  These  are  thickest  about  the  urethral 
orifice,  forming  the  internal  vesical  sphincter.  The  inner  layer  is 
made  up  of  longitudinal  fibres  passing  from  the  apex  to  the  neck. 
The  fibres  composing  this  layer  are  grouped  in  bundles  or  fascicuh, 
which  anastomose,  forming  a  coarse  net-work  and  producing  the 
characteristic  reticulation  of  the  inner  surface. 

Vascularization  and  Innervation. — Blood  is  carried  to  the  bladder 
by  branches  of  the  internal  iliac  arteries.  These  are  the  superior 
vesical,  supplying  the  apex  and  the  lateral  surfaces  and  deferent  canals  ; 
the  middle  vesical,  supplying  the  base  of  the  bladder  and  the  seminal 
vesicles ;  the  inferior  vesicals,  often  from  the  middle  hemorrhoidal, 
running  to  the  prostate,  the  seminal  vesicles,  and  the  trigonum  ;  and 
the  anterior  vesicals,  small  and  variable,  derived  from  the  internal 


390  GENITO-URINAKY    DISEASES   AND   SYPHILIS. 

iliac  or  the  obturator.  These  blood-vessels  penetrate  the  muscular 
coats  of  the  bladder,  forming  a  submucous  plexus  from  which  the 
epithelial  capillaries  are  given  off. 

The  veins  of  the  mucous  membrane,  having  penetrated  the  mus- 
cular coat,  form  a  superficial  plexus,  made  up  of  large,  freely  anas- 
tomosing, valved  trunks,  usually  running  longitudinally.  The  ante- 
rior vesical  veins  pass  into  the  pubo-prostatic  plexus  (plexus  of 
Santorini),  situated  just  beneath  the  symphysis  to  the  right  and  left 
of  the  median  line  ;  the  lateral  veins,  particularly  voluminous  and 
numerous,  empty  into  the  vesico-prostatic  plexus.  The  posterior 
veins,  also  large,  pass  into  the  vesico-prostatic  plexus  or  seminal 
plexus.  The  pubo-prostatic,  the  vesico-prostatic,  and  the  seminal 
plexus  anastomose  freely,  and  practically  form  one  series  of  large 
vessels,  which  is  emptied  by  all  the  veins  lying  near  at  hand,  in- 
cluding the  hypogastric,  the  ureteric,  the  hemorrhoidal,  the  internal 
pudic,  the  obturator,  and  the  spermatic. 

The  lymphatics  of  the  upper  two  thirds  and  lower  anterior  third 
and  neck  of  the  bladder  drain  into  the  external  iliac  ganglia,  those  of 
the  posterior  third  into  the  hypogastric  or  presacral  glands. 

The  nerves  of  the  bladder  are  derived  from  the  hypogastric  plexus 
and  from  the  anterior  branches  of  the  third  and  fourth  sacral  nerves. 

At  the  bladder  base  hes  the  trigonum,  presenting  a  smooth  red 
surface,  in  the  form  of  a  nearly  equilateral  triangle,  each  side  of  which 
is  about  one  and  a  quarter  inches  long.  The  angles  correspond  in 
position  to  the  internal  vesical  orifice  and  the  two  slight  projections 
or  openings  of  the  ureters.  The  triangle  may  be  distinctly  outlined 
by  perceptible  ridges  passing  betw^een  the  two  ureteral  openings 
and  from  these  to  the  internal  vesical  orifice.  (Fig.  131.)  These 
ridges  represent  a  reinforcement  of  the  vesical  and  ureteral  muscles, 
designed  to  preserve  the  valve-like  action  of  the  ureters  and  to  keep 
them  closed  against  back  pressure  from  the  bladder.  The  region  of 
the  vesical  triangle  is  indicated  on  the  outer  surface  of  the  bladder  by 
the  position  of  the  seminal  vesicles.  When  these  are  normally  de- 
veloped, a  hue  joining  their  posterior  extremities  indicates  the  base 
of  the  triangle ;  the  point  where  the  bladder-wall  merges  into  the 
mid-portion  of  the  prostate  indicates  its  apex. 

The  trigonum  and  the  vesical  neck  are  more  abundantly  supplied 
with  blood-vessels  and  nerves  than  are  any  other  portions  of  the 
bladder. 

It  follows  from  the  position  of  the  bladder  that  it  is  well  pro- 
tected from  direct  traumatism,  and  that  it  is  accessible  to  exploration 
by  combined  rectal  and  suprapubic  palpation.     Its  abundant  blood- 


INJURIES   AND    DISEASES   OF    THE    BLADDER. 


591 


supply  assures  quick  healing  of  surgical  or  accidental  wounds  when 
other  conditions  favorable  for  healing  are  present.  The  superficial 
layers  of  flat  "epithehum  with  which  the  mucous  membrane  is  pro- 
vided insure  against  absorption  from  the  bladder  as  long  as  the  epi- 
thelium remains  healthy  and  unbroken,  thus  protecting  the  system 
against  poisoning  by  toxic  substances  eliminated  with  the  urine  and 
guarding  the  tissues  locally  against  infection.  The  loose  attachment 
of  the  mucous  membrane  to  the  underlying  muscular  tissues  and  the 
arrangement  of  the  muscular  coat  prevent  extravasation  of  urine  after 


Vesical  triangle.  (Sappey.)  1,  surface  of  the  triangle  ;  2,  2,  posterior  angles  and  ureteral  openings  -, 
3,  anterior  angle  representing  the  urethral  opening  ;  4,  slight  pouching  behind  the  triangle  ;  5,  5,  ter- 
minal extremities  of  the  ureters ;  6,  upper  portion  of  the  bladder  sphincter  ;  7,  constrictor  muscles  of 
the  prostatic  urethra;  8,  8,  plexus  of  Santorini;  9,  9,  vesico-prostatic  plexus;  10,  10,  cross-section  of 
these  veins  at  the  point  where  they  reach  the  lateral  portion  of  the  base  of  the  bladder. 


puncture  of  a  full  bladder,  the  opening,  on  withdrawal  of  the  needle 
or  trocar,  becoming  valvular  by  the  sliding  of  the  tissues.  The  great 
venous  plexus  at  the  base  of  the  bladder  and  the  many  large  veins 
passing  over  its  surface,  together  with  the  free  intercommunication 
between  all  the  pelvic  veins,  explain  the  frecjuency  of  dangerous 
venous  bleeding  in  bladder  surgery.  These  facts  also  show  how 
important  an  effect  upon  the  bladder  is  exerted  by  any  cause,  such 
as    constipation,   producing   pelvic    engorgement.     The   particularly 


392  GENITO-UEINARY   DISEASES    AND   SYPHILIS. 

generous  innervation  and  vascularization  of  the  trigonum  and  the 
bladder-neck  explain  the  greater  pain  and  reaction  from  inflammation 
or  manipulation  of  this  part  of  the  viscus. 

MALFORMATIONS    AND    MALPOSITION    OF   THE    BLADDER. 

The  bladder  may  be  multiple.  Its  walls  may  be  absent  in  whole 
or  in  part,  may  be  hypertrophied,  atrophied,  or  herniated.  The 
urachus  may  remain  patulous. 

Multiple  bladder,  in  the  true  sense  of  the  term,  is  an  extremely 
rare  deformity.  Usually  there  is  a  single  bladder  with  a  septum 
running  fore  and  aft  or  obliquely  or  even  transversely.  The  ureters 
open  into  the  main  bladder  cavity.  More  frequently  it  is  a  sacculated 
bladder.  Sometimes  the  apparent  anomaly  is  due  to  the  enormous 
dilatation  of  a  ureter. 

When  the  bladder  is  really  multiple,  as,  for  instance,  in  a  reported 
case  in  which  there  were  five  kidneys,  each  with  a  separate  re- 
ceiving viscus,  no  operative  measure  is  indicated.  Sacculation,  with 
attendant  cystitis  from  defect  of  drainage,  would  indicate  simply  the 
treatment  of  the  cystitis.  Enormous  dilatation  of  the  ureter,  if  it  could 
be  diagnosed,  would  indicate  the  relief  of  the  stricture  or  the  forma- 
tion of  a  new  opening  between  the  dilated  ureter  and  the  bladder. 

Complete  Absence  of  the  Bladder. — When  the  bladder  is 
completely  absent,  the  ureters  open  into  the  urethra,  the  vagina,  the 
rectum,  or  the  umbilicus.  The  condition  may  be  treated  by  the  ap- 
plication of  a  urinal,  which  prevents  the  garments  from  being  soiled, 
or  by  implantation  of  the  ureters  into  the  bowels. 

Exstrophy,  or  absence  of  a  portion  of  the  bladder-wall,  is  by  no 
means  uncommon.  The  anterior  wall  is  the  portion  usually  wanting, 
though  cases  are  reported  in  which  the  septum  separating  the  blad- 
der from  the  vagina  or  the  rectum  has  been  absent.  Exstrophy  or 
extroversion  is  observed  most  frequently  in  male  children,  and  is  due 
to  the  failure  of  the  lateral  portions  of  the  uro-genital  cleft  to  unite. 
Hence  in  pronounced  cases  there  is  a  deficiency  not  only  in  the  ante- 
rior wall  of  the  bladder  but  also  in  the  musculo-cutaneous  abdominal 
parietes  and  the  pelvic  girdle,  the  pubes  not  meeting  in  the  middle 
line  to  form  the  symphysis.  This  deformity  is  associated  with  epi- 
spadia in  the  male  and  split  clitoris  in  the  female,  the  bladder  and 
urethra  opening  in  the  female  either  into  the  vagina  or  just  above  it. 
From  weakness  of  the  abdominal  parietes  there  is  commonly  asso-, 
ciated  with  this  deformity  complete  double  inguinal  hernia,  which, 
descending  into  the  cleft  scrotum,  causes  its  two  halves  closely  to 
resemble  the  labia  majora  of  the  female.     The  prostate  is  rudimen- 


INJURIES    x\.ND    DISEASES    OF    THE    BLADDEE.  393 

tary,  the  testicles  often  are  ectopic.  The  recti  muscles  pass  upward 
and  inward  on  either  side  from  their  insertion  into  the  separated 
pubis.  Sometimes  this  separation  is  continued  upward  almost  to  the 
origin  of  the  muscles,  allowing  the  formation  of  ventral  hernia. 

On  examining  a  case  of  exstrophy  of  the  bladder  there  is  found 
presenting  in  the  hypogastric  and  pubic  region  a  bulging,  moist,  dark 
red  surface  of  intensely  inflamed  rugous  mucous  membrane,  sur- 
rounded by  an  area  of  cicatricial  tissue,  uniting  its  borders  to  the 
skin.  This  projection  varies  in  size  from  that  of  a  half  walnut  in  in- 
fants to  that  of  a  man's  fist  in  adults.  It  bleeds  readily,  is  extremely 
sensitive,  its  lower  portion  is  wet,  and  the  projections  marking  the 
ureteral  orifices  can  usually  be  found  by  the  escape  of  urine,  which 
spirts  from  them  in  jets.  This  tumefaction  may  extend  upward  as 
far  as  the  umbilicus. 

Continuous  with  the  lower  border  of  the  mucous  surface  is  the 
urethra,  passing  as  a  furrow  on  the  dorsal  aspect  of  the  rudimentary 
penis,  the  prepuce  of  which  forms  a  large  flap  hanging  from  the  under 
surface  of  the  glans.  The  pubes  may  be  separated  for  a  distance  of 
one  or  two  inches.  The  seminal  vesicles  are  either  absent  or  are 
greatly  atrophied.  The  ureters  are  often  dilated,  and  sometimes  so 
sharply  bent  that  consequent  obstruction  and  dilatation  occur.  In 
the  female  the  greater  and  lesser  vulvar  lips  are  not  joined  ante- 
riorly, and  the  clitoris  is  split,  the  vagina  being  converted  into  a 
small  channel.  Patients  exhibiting  this  deformity  are  usually  of  poor 
physical  development  in  olher  respects,  and  often  perish  from  ascend- 
ing pyelonephritis.  As  a  result  of  the  leakage  of  urine  inseparable 
from  exstrophy,  the  surrounding  skin  becomes  infiltrated  and  exco- 
riated, and  erysipelas  sometimes  develops.  Sexual  desire  is  gener- 
ally wanting,  though  in  the  female  this  deformity  does  not  necessarily 
interfere  with  parturition. 

Associated  deformities  are  by  no  means  uncommon.  At  times  the 
intestine  or  the  anus  opens  through  the  exstrophied  mucous  mem- 
brane. Generally  the  anus  is  placed  farther  forward  than  normal. 
Spina  bifida  and  club-foot  may  be  associated  with  exstrophy. 

In  degree  exstrophy  varies  from  the  slight  form  characterized  by 
epispadia  and  a  cicatricial  condition  of  the  skin  in  the  neighborhood 
of  the  pubis  to  the  form  in  which  there  is  separation  of  the  pubic 
bones,  or,  finally,  to  the  form  characterized  by  complete  hypogastric 
fissure  with  eventration.  Between  these  extreme  degrees  of  exstrophy 
there  is  every  gradation.  Heredity  exerts  no  influence  in  causing  this 
deformity. 

The  diagnosis  of  exstrophy  is  unmistakable.     The  scar-tissue  sur- 


394 


GENITO-URIJSTARY   DISEASES   AND   SYPHILIS. 


Fig.  132. 


rounding  the  mucous  membrane  is  congenital,  and  is  not  due  to  pre- 
vious destructive  inflammation. 

The  prognosis  must  be  guarded,  since  the  conditions  are  favorable 
to  kidney-infection. 

Treatment  may  be  either  palliative  or  radical.  Palliative  treatment 
consists  in  the  application  of  a  urinal  so  constructed  that  a  hollow 
rubber  cup  accurately  fits  the  skin  surface  surrounding  the  cleft,  and 
thus  enables  the  nrine  to  be  drained  off  into  a  reservoir.  (Fig,  132.) 
Radical  operation  consists  in  closing  the  defect  by  plastic  opera- 
tions, or  in  diverting  the  ureters. 

The  most  successful  radical  operation  can  never  make  a  satis- 
factorily retentive  bladder,  since  a  sphincter  which  will  be  under 

proper  nervous  control  cannot  be 
formed.  •  Plastic  operations  usu- 
ally aim  to  lessen  deformity  and 
to  close  the  bladder  sufficiently  to 
allow  of  easy  drainage  by  means  of 
a  urinal,  thus  protecting  the  sur- 
rounding skin  from  irritation  and 
enabling  the  patient  to  keep  himself 
clean.  Wood's  operation  is  the  one 
most  in  favor.  A  cutaneous  flap, 
the  attachment  of  which  corre- 
sponds to  the  upper  border  of  the 
cleft,  is  turned  down  from  above  the 
bladder.  This  flap  should  be  of  suf- 
ficient length  to  cover  entirely  the 
exposed  mucous  membrane ;  the 
skin  surface  thus  forms  a  new  an- 
terior wall  for  the  bladder.  The  lateral  borders  of  this  flap  are 
sutured  with  catgut  to  the  freshened  skin  borders  of  the  congenital 
cleft.  There  is  thus  formed  a  pouch,  the  anterior  wall  of  skin,  the 
posterior  of  mucous  membrane.  The  raw  outer  surface  of  this  first 
flap  is  then  covered  in  by  two  lateral  rectangular  flaps  which  have 
their  attached  bases  placed  in  the  inguinal  region  of  each  side.  These 
two  flaps  are  made  of  such  length  that  without  undue  tension  they 
can  be  carried  transversely  across  the  raw  surface  of  the  first  flap, 
covering  it  completely.  The  free  borders  of  these  flaps  are  sewed 
together  with  silkworm-gut.  Finally,  the  large  wound  resulting  from 
the  transplantation  of  these  flaps  is  closed  in  as  far  as  possible  by 
means  of  silk  sutures. 
-    Closure  of  the  bladder  by  direct  suture  possesses  the  advantage 


A,  day  urinal,  1,  detachable  reservoir. 
B,  night  and  day  urinal;  2,  detachable  reser- 
voir. 


INJURIES  AND  DISEASES  OF  THE  BLADDER. 


395 


of  forming  a  vesical  cavity  consisting  entirely  of  mucous  membrane. 
When  there  is  bone-defect,  an  essential  point  in  successfully  perform- 
ing this  operation  is  the  approximation  of  the  two  pubic  bones.  This 
may  be  accomplished  in  infants  by  subcutaneous  symphyseotomy  of 
the  sacroiliac  joints,  followed  by  forcible  lateral  pressure  and  the  ap- 
plication of  a  gravity  apparatus. 

Moynihan  successfully  treated  a  case  of  exstrophy  of  the  bladder 
by  transplanting  this  viscus  in  the  bowel.  He  made  an  incision 
around  the  margin  of  the  mucous  membrane  of  the  bladder  between 
the  mucosa  and  the  skin  and  deepened  this  until  a  good  thickness  of 
the  bladder  wall  could  be  raised  up.  The  whole  bladder  was  finally 
freed  except  for  the  pedicle  made  up  of  the  two  ureters  with  as  much 
tissue  around  them  as  possible.  Into  these  there  had  been  pre- 
viously passed  catheters  for  a  distance  of  about  four  inches  secured  in 
place  by  a  single  stitch,  catching  up  the  tube  on  one  side  and  the 
bladder  on  the  other.  The  bladder  was  drawn  upward  toward  the 
umbilicus  and  there  held  exposing  at  the  bottom  of  the  wound  the 
rectum  below  its  peritoneal  investment  which  was  stripped  upward 
until  five  or  six  inches  of  the  bowel  lay  exposed.  An  assistant  passed 
his  finger  into  the  rectum  thus  making  it  prominent.  Along  its  ante- 
rior surface  an  incision  three  and  one-half  inches  long  was  made. 
Into  this  opening  the  bladder  was  placed  upside  down  so  that  its 
former  anterior  surface  became  posterior  and  its  former  lower  end 
became  the  upper.  The  ureters  instead  of  passing  forward  passed 
backward,  the  catheters  being  introduced  into  the  rectum  and  being 
brought  out  into  the  anus.  The  cut  edges  of  the  rectum  and  the 
bladder  were  sutured  together  by  two  stitches  that  were  continuous, 
one  taking  the  right  side  and  the  other  the  left.  The  Lembert 
sutures  were  so  used  that  no  mucous  membrane  was  included  in 
them.  The  skin  edges  along  the  median  incision  were  drawn  together. 
About  an  inch  at  the  lower  part  had  to  be  left  open.  The  operation 
lasted  an  hour  and  a  half.  The  catheters  were  left  in  the  ureters  for 
four  days,  the  urine  being  collected  in  a  bottle.  Thereafter  it  dribbled 
from  the  anus  because  of  the  sphincteric  relaxation  incident  to 
over-stretching.  After  a  week  there  was  some  leakage  of  urine 
through  the  abdominal  wound.  This  was  remedied  by  a  deep  suture. 
At  the  end  of  a  month  control  was  perfect,  the  urine  passing  by 
the  rectum  about  every  two  hours.  At  the  end  of  eight  months  the 
urine  was  entirely  normal,  and  proctoscopical  examination  failed  to 
show  demarcation  between  the  mucous  membrane  of  the  rectum  and 
that  of  the  bladder.  The  shortest  period  of  retention  was  three 
hours,  the  longest  five. 


396  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

Maydl  has  successfully  accomplished  this  transplantation  by  open- 
ing the  peritoneal  cavity  at  the  border  of  the  exstrophied  bladder  and 
removing  the  whole  of  the  latter  except  a  small  segment  containing 
the  ureteral  orifices.  Into  the  ureters  are  passed  small  catheters.  The 
small  bladder-segment  left,  together  with  the  attached  ureters,  is  thor- 
oughly mobilized ;  the  colon  is  drawn  out  and  incised  longitudinally, 
and  in  this  opening  is  secured  the  portion  of  the  bladder-wall  con- 
taining the  ureters.  The  mucous  membrane  is  first  sewed  to  the 
mucous  membrane  of  the  gut,  then  the  musculo-peritoneal  coating 
of  the  intestine  is  sutured  to  the  muscular  wall  of  the  bladder-segment. 
Finally  the  abdominal  wound  is  closed  by  suture. 

Orloff  collected  fifty-six  cases  of  Maydl's  operation.  Eleven  cases 
died  within  twenty-one  days  after  operation ;  four  from  peritonitis. 
Of  the  forty-five  remaining  cases  only  five  died  of  the  later  results  of 
ascending  infection.  The  post-operative  complications  have  been  pneu- 
monia in  six  cases,  faecal  fistula  in  seven  cases,  phlebitis  of  the  leg  in 
one.  Some  renal  colic  and  albuminuria  were  noted  in  nearly  all. 
There  is  little  irritation  of  the  bowel  and  the  anal  sphincter  remains 
competent. 

Peters  {Canadian  Journal  of  Medicine  and  Sm-gery,  April,  1902) 
describes  in  detail  an  excellent  method  of  implanting  the  ureters  into 
the  rectum  by  the  extra-peritoneal  route. 

A  consideration  of  the  various  operative  methods  applicable  to 
exstrophy  leads  us  to  believe  that  in  certain  appropriate  cases  the 
method  of  choice  is  direct  suture  of  the  freshened  bladder-borders, 
thus  forming  an  irregular  cylinder,  which  acts  not  as  a  reservoir  but 
as  a  conductor  of  urine,  allowing  a  portable  urinal  to  be  employed. 
In  children  an  effort  should  be  made  to  close  the  bony  defect  by 
elastic  or  weight  pressure.  Symphyseotomy  is  by  no  means  free 
from  danger.  The  exact  value  of  this  procedure  and  the  additional 
risk  inseparable  from  it  remain  yet  to  be  determined.  When  suc- 
cessful, it  enables  the  surgeon  to  close  the  bladder  and  a  part  of 
the  urethra  by  direct  suture. 

When  flaps  are  required  to  close  the  defect,  these  should,  when 
possible,  be  of  mucous  membrane  made  at  the  expense  of  the  ex- 
strophied bladder.  It  would  seem  advisable  to  use  the  whole  thick- 
ness of  the  bladder-wall.  This  requires  opening  of  the  peritoneal 
cavity,  and,  since  the  tissues  operated  on  are  infected,  may  cause 
peritonitis.  Careful  preliminary  cleansing  of  the  parts  and  the  skilful 
use  of  intraperitoneal  pads  should  prevent  this  danger. 

Wood's  operation,  while  objectionable  because  skin  surfaces  are 
turned  in,  is  on  the  whole  the  one  which  with  the  least  risk  combines 


INJUKIES    AND    DISEASES   OF    THE    BLADDER.  397 

the  greatest  advantages.  The  result  is  not  so  satisfactory  as  that  fol- 
lowing direct  suture,  but  the  percentage  of  cases  to  which  the  latter 
method  is  applicable  is  far  less,  and  the  proportion  of  operative  suc- 
cesses by  Wood's  operation  is  greater. 

Ureteral  derivation  is  theoretically  the  most  satisfactory  immediate 
treatment  of  exstrophy. 

Before  any  operation  is  performed  the  inflamed  skin  surrounding 
the  bladder  must  be  rendered  healthy  by  cleansing  washes  and  heal- 
ing protective  salves.  Thus,  twice  daily  the  parts  may  be  bathed  in 
five  per  cent,  ichthyol  solution,  followed  by  the  application  of  a  thick 
zinc  paste,  made  by  adding  four  drachms  of  finely  powdered  zinc 
oxide  to  an  ounce  of  benzoated  zinc  ointment.  This  paste  is  removed 
by  rubbing  with  cosmoline. 

Congenital  diverticulum  always  causes  hypertrophy  of  the 
bladd'er  wall,  and  ultimately  is  likely  to  exhibit  the  lesions  of  intense 
inflammation.  Not  infrequently  of  stone  formation.  The  most  pro- 
nounced symptom  is  frequent  urination,  which  later,  with  the  onset 
of  inflammation,  may  be  painful.  There  is  commonly  a  sensation  as 
though  the  bladder  had  not  been  completely  evacuated,  and  after  the 
act  of  micturition  more  urine  can  usually  be  voided.  Occasionally 
attacks  of  retention  occur.  Diverticulum  may  form  a  distinct  tumor 
which  may  be  palpable  either  over  the  pubis  or  in  the  sacral  concavity 
by  rectal  examination.  Catheterization  will  draw  off  the  urine  in  the 
bladder,  and  by  pressure  a  further  quantity  can  be  evacuated,  often 
exhibiting  pus  in  considerable  quantity.  With  the  evacuation  of  this 
added  quantity  the  tumor  will  disappear.  Cystoscopic  examination 
will  show  the  opening  into  the  diverticulum.  At  times  lamps  can  be 
passed  through  the  opening,  or  at  least  catheters  can  be  introduced. 
Diverticular  openings  usually  lie  near  the  ureteral  orifice. 

Treatment  may  be  by  free  drainage  into  the  bladder  or  by  excision. 
The  condition,  when  complicated  by  cystitis,  exhibits  a  distinct  pre- 
dilection for  middle  aged  males.  In  the  absence  of  cystitis  it  is  mainly 
symptomless. 

The  diverticulum  if  it  gives  trouble  is  treated  by  extirpation,  usually 
a  difficult  operation,  access  being  gained  either  by  the  suprapubic  or 
the  sacral  route. 

Patent  Urachus, — Occasionally,  as  a  congenital  defect,  the  com- 
munication between  the  bladder  and  the  allantois  is  not  entirely  oblit- 
erated, and  after  birth  urine  escapes  through  the  umbilicus.  This 
condition  is  usually  due  to  the  back  pressure  incident  to  urethral 
obstruction. 


398  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

Treatment  consists  in  first  rendering  the  urethra  patulous.  This 
in  itself  is  often  sufficient  to  produce  a  cure.  If  the  fistula  still  per- 
sists, an  occluding  dressing,  the  application  of  the  actual  cautery,  or 
excision  of  the  sinus  is  indicated.  Urinary  concretions  and  suppu- 
rating pouches  may  form.  These  may  not  communicate  with  the 
bladder  but  may  discharge  through  the  umbilicus,  pus,  without  an 
urinous  mixture,  or,  if  the  umbilical  opening  becomes  occluded,  may 
form  prevesical  tumors  or  abscesses.  The  only  treatment  of  service 
is  complete  dissection  of  the  suppurating  sac. 

Hypertrophy  of  the  Bladder. — This  term  implies  an  over- 
growth of  the  vesical  muscles.  Sometimes  it  is  associated  with 
marked  thickening  of  the  mucosa.  It  is  always  caused  by  increased 
functional  activity  incident  to  mechanical  obstruction  to  the  escape  ol 
urine  from  the  bladder  or  to  abnormally  frequent  micturition. 

Fig.  133. 


^a 


V 


Concentric  hypertrophy  of  the  bladder. 


In  cases  of  obstruction,  particularly  if  it  is  at  the  vesical  neck, 
there  is  usually  coincident  with  hypertrophy  a  dilatation,  often  a 
partial  sacculation,  of  the  bladder,  the  weaker  portions  of  the  walls 
between  the  thickened  muscular  fascicuh  yielding.  In  vigorous  young 
men,  and  this  particularly  represents  the  type  suffering  from  chronic 
stricture,  muscular  hypertrophy  may  be  universal,  the  resulting  in- 
creased expulsive  force  of  the  bladder  preventing  retention  and  sec- 
ondary dilatation.  In  older  men,  with  enlarged  prostates,  the  typi- 
cally dilated,  thickened,  trabeculated,  and  possibly 'sacculated  bladder 
develops.  Hypertrophy  dependent  upon  frequent  urination  without 
obstruction,  as  in  some  cases  of  chronic  posterior  urethritis,  is  always 


INJURIES    AND   DISEASES    OP   THE    BLADDER.  399 

concentric  and  lessens  the  size  of  the  vesical  cavity.  Cystitis  is  usu- 
ally associated  with  hypertrophy,  adding  to  the  thickness  of  the  blad- 
der-walls.    (Fig.  133.) 

The  ultimate  prognosis  of  hypertrophy  is  bad,  since  fibroid  or 
fatty  degeneration  is  liable  to  occur,  with  consequent  diminution  or 
entire  loss  of  contractile  power. 

Diagnosis. — This,  when  the  hypertrophy  is  associated  with  trabec- 
ulation  and  dilatation,  is  made  either  by  the  cystoscope  or  by  examina- 
tion with  a  vesical  sound.  Even  when  the  bladder  is  well  distended, 
the  point  of  the  explorer  can  be  felt  scraping  and  jolting  over  the 
ridges  made  by  the  hypertrophied  muscular  fasciculi.  When  there 
is  concentric  hypertrophy  without  dilatation,  the  lessened  capacity 
of  the  bladder  and  the  detection  of  its  greatly  thickened  walls  by  bi- 
manual rectal  and  suprapubic  palpation,  together  with  a  preceding 
history  of  either  frequent  or  difficult  micturition,  point  to  the  true 
nature  of  the  affection. 

Treatment. — The  direct  treatment  of  the  hypertrophy  is  unavailing. 
Relief  of  obstruction  or  of  the  necessity  for  frequent  micturition  will 
prove  curative  if  this  is  accomplished  before  degenerative  changes 
have  begun. 

Atrophy  of  the  bladder  may  be  caused  by  distention  or  by 
degeneration  consequent  on  nerve-lesion.  In  old  age  there  has  been 
observed  a  fatty  degeneration  of  both  the  detrusor  and  sphincter  mus- 
cles. As  a  result  of  muscular  atrophy  the  bladder  loses  the  power 
of  evacuating  its  contents  and  becomes  a  thin,  sometimes  enormously 
dilated  pouch.  If  the  sphincters,  including  the  compressor  urethras 
muscle,  are  atrophied,  there  will  result  incontinence  of  urine ;  this 
symptom  is  usually  associated  with  retention. 

Atony  of  the  Bladder. — Weakness  of  the  bladder  muscularis, 
almost  physiological  in  people  past  middle  life,  is  usually  due  to  over- 
distention,  which  may  be  acute  and  temporary  as  from  lack  of  privacy 
for  an  urgently  desired  act  of  micturition,  sudden  urethral  obstruction, 
or  post-traumatic  retention,  or  may  be  chronic  and  persistent  as  from 
gradually  developed  urethral  obstruction  or  habitual  deferring  of  the 
act  of  micturition.  The  hypertrophied  bladder  inevitably  becomes 
atonic,  as  does  the  viscus  which  is  subject  to  prolonged  drainage. 
The  atonic  bladder  may  form  a  thin,  enormous  pouch,  containing 
many  pints  of  fluid  (Fig.  134),  or,  if  associated  with  hypertrophy,  may 
exhibit  a  capacity  even  less  than  normal. 

Diagnosis. — This  is  based  on  the  history  of  an  adequate  cause, 
since  except  in  the  aged  and  in  those  subject  to  exhausting  fevers 
atony  is  never  primary.      The  stream  of  urine  lacks  in  propulsive 


400 


GENITO-URINARY   DISEASES    AND  SYPHILIb. 


force  even  when  a  catheter  is  passed,  unless  the  abdominal  muscles 
are  brought  into  play.  There  is  always  some  residuum  after  urina- 
tion, hence  frequency  of  urination  is  usually  noted. 

Treatment. — After  removal  of  the  cause  and  the  cure  of  the  com- 
monly accompanying  cystitis,  the  atonic  condition  of  the  vesical  mus- 
cles may  be  benefited  by  strychnine,  irrigations  with  hot  normal  salt 
solution,  and  the  use  of  the  slowly  interrupted  faradic  current,  one 

Fig.   134. 


Atony  of  the  bladder,  with  dilatation. 


1  From  a  specimen  m  the  Museum  of  the  PhUadelpMa 
Hospital.) 


electrode  being  introduced  into  the  bladder,  which  should  contain  not 
more  than  four  ounces  of  fluid. 

Hernia  of  the  Bladder.— Under  this  term  is  included  protrusion 
of  a  part  of  the  bladder-wall  along  the  track  usually  taken  by  intes- 
tinal hernia.  Inguinal  cystocele  is  the  common  form,  though  there  are 
instances  of  obturator,  crural,  and  perineal  vesical  hernia. 


INJURIES   AND   DISEASES    OF    THE    BLADDER.  4OI 

Inguinal  cystocele  may  appear  in  the  form  of  a  projection  of  the 
bladder  without  a  true  hernial  sac, — that  is,  without  a  peritoneal 
covering, — the  muscular  coat  of  this  viscus  lying  in  immediate  con- 
tact with  the  transversalis  fascia  and  adhering  to  it.  This  is  the  usual 
form,  and  rarely  attains  large  dimensions.  Exceptionally  there  is 
partial  or  complete  sacculation  at  the  expense  of  the  peritoneal  in- 
vestment of  the  bladder.  Still  more  rarely  the  herniated  bladder 
forms  a  tumor  entirely  covered  by  its  own  peritoneum  and  invested 
in  an  additional  true  peritoneal  sac.  Either  the  summit  or  the  lateral 
surface  of  the  bladder  is  the  portion  found  prolapsed.  Even  the 
most  pronounced  displacement  is  not  sufficiently  extensive  to  displace 
the  ureters. 

The  herniated  portion  of  the  bladder  usually  presents  thin  walls, 
is  often  surrounded  with  considerable  fat,  and  sometimes  appears  as 
a  diverticulum  with  an  extremely  small  opening  into  the  general 
vesical  cavity,  the  capacity  of  the  latter  not  being  particularly  dimin- 
ished. From  stagnation  of  the  urine  in  these  diverticula  calculi  may 
form. 

The  causes  of  hernia  of  the  bladder  are  overdistention  and  dila- 
tation of  this  organ  and  a  patulous  condition  of  the  hernial  orifices. 
When  the  bladder  is  the  first  viscus  to  appear  in  the  hernial  region, 
its  anterior  surface,  uncovered  by  peritoneum,  descends,  possibly 
dragged  down  by  a  preceding  lipomatous  formation.  After  this  fol- 
lows the  part  covered  by  peritoneum,  forming  an  artificial  sac,  into 
which  the  gut  may  subsequently  descend.  The  most  frequent  cause 
of  bladder  hernia  is  a  preceding  intestinal  hernia,  which,  as  it  pro- 
gresses and  drags  on  the  peritoneum  in  the  formation  of  a  sac,  in- 
volves the  bladder. 

Symptoms. — The  characteristic  symptom  of  hernia  of  the  bladder 
is  the  presence  of  a  fluctuating  tumor,  dull  on  percussion  and  varying 
in  size  in  accordance  with  the  amount  of  urine  contained  in  the 
bladder.  This  tumor  may  not  grow  smaller,  even  though  the  bladder 
be  completely  emptied,  since  it  may  communicate  by  a  small  orifice, 
which  is  closed  when  the  patient  is  in  the  erect  position.  On  lying 
down,  however,  and  particularly  after  manipulation  and  gentle 
pressure  which  causes  a  desire  to  urinate,  the  somewhat  tense  fluctu- 
ating tumor  becomes  small  and  flaccid,  and  immediately  a  quantity 
of  urine  can  be  again  evacuated.  The  flaccid,  inconspicuous  swelling 
becomes  tense  and  full  when  injections  are  forced  into  the  bladder. 
These  symptoms  are  absolutely  diagnostic.  In  addition  there  are 
often  symptoms  of  bladder  irritation,  such  as  frequent  and  difficult 
urination,    retention,   or   evident   cystitis.      Exceptionally,  when   the 


402  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

herniated  portion  of  the  bladder  is  small,  it  offers  no  symptoms 
other  than  those  associated  with  an  irreducible  omental  hernia. 

Vesical  hernia  is  commonly  complicated  by  enterocele  or  epiplo- 
cele.  Usually  this  displacement  is  not  suspected  till,  in  the  course  of 
operation  for  intestinal  hernia,  escape  of  urine  shows  that  the  bladder 
has  been  opened. 

Treatment  for  this  affection  should  be  operative.  A  truss  is  not 
well  borne,  and  reduction  is  impossible.  The  operation  consists  in 
carefully  dissecting  the  bladder  free  of  its  adhesions,  reducing  it  to  its 
proper  position,  and  permanently  closing  the  hernial  opening. 

WOUNDS,  CONTUSION,  AND  RUPTURE  OF  THE  BLADDER. 

The  bladder  when  empty  is  so  deeply  placed,  so  well  protected 
by  the  bones  of  the  pelvis,  and,  moreover,  so  movable,  at  least  in  its 
upper  part,  that  it  usually  escapes  the  effects  of  even  severe  trauma- 
tism. When  force  has  been  applied  sufficient  to  fracture  the  pelvic 
bones  or  to  cause  disjunction  at  the  pubic  symphysis,  even  the  empty 
bladder  may  be  bruised,  punctured,  or  lacerated.  Horns,  weapons, 
or  pointed  stakes  may  wound  this  viscus  when  driven  into  the  peri- 
neum or  rettum,  through  the  obturator  or  sciatic  foramen,  or  above 
the  pubis.  Bullets  may  reach  the  bladder  either  through  the  outlets 
of  the  pelvis  or  directly  through  its  bony  substance.  Rough  instru- 
mentation may  cause  laceration  of  the  vesical  walls.  Finally,  when 
the  bladder  is  full  or  overdistended,  force  applied  from  without,  even 
though  insufficient  to  cause  disjuncture  of  the  pelvic  bones  or  super- 
ficial bruising,  may  occasion  either  contusion  or  rupture  of  the 
bladder. 

Wounds  of  the  Bladder. — The  term  wound  implies  a  solution 
of  the  continuity  of  the  soft  parts  extending  from  the  skin  surface 
down  to  the  bladder-lesion.  Rupture  and  contusions  will  be  sepa- 
rately considered.  Nearly  all  wounds  of  the  bladder  can  be  classed  as 
contused  or  lacerated,  including  under  these  headings  gunshot  wounds. 

Incised  wounds  are  usually  inflicted  by  the  surgeon,  either  inten- 
tionally, as  in  cystotomy,  or  accidentally,  as  in  extirpation  of  pelvic 
tumors.  In  the  latter  case  prompt  closure  of  the  wound  by  suture  is 
nearly  always  followed  by  immediate  union,  the  danger  incident  to 
this  accident  lying  in  the  risk  that  it  may  be  overlooked.  When  the 
wound  does  not  entirely  penetrate  the  visceral  wall,  involving,  for  in- 
stance, the  serous  and  muscular  coats  only,  the  mucous  coat  remaining 
intact  prevents  extravasation,  and  cicatrization  is  unhindered. 

Contused  and  lacerated  wounds,  the  common  variety,  are  usually 
inflicted  by  way  of  the  perineum  or  the  rectum,  as  the  result  of  a  fall 


INJURIES   AND    DISEASES    OF    THE    BLADDER.  403 

upon  a  stake  or  a  paling,  or  are  due  to  wounding  by  firearms.  They 
are  also  caused  by  inadvertence  in  surgical  manipulations.  Thus, 
Neumann  in  extracting  a  stone  adherent  to  the  vesical  wall  in  a  boy, 
aged  nine,  tore  an  opening  through  both  bladder  and  rectum.  In 
accordance  with  the  portion  of  the  bladder  involved  the  wound  is 
termed  intraperitoneal  or  extraperitoneal.  From  the  stand-point  of 
prognosis  this  classification  is  highly  important. 

Symptoms. — The  symptoms  of  wound  of  the  bladder  are — 1,  escape 
of  urine  through  the  wound ;  2,  frequent  straining  efforts  at  urination, 
with  the  passage  of  blood  or  bloody  urine ;  3,  the  detection  of  an 
opening  in  the  bladder  by  means  of  a  probe  passed  through  the 
wound,  or  of  a  sound  passed  through  the  urethra,  aided  by  digital 
examination  per  rectum,  or  by  a  combination  of  these  methods  ;  4, 
shock. 

All  these  symptoms  may  be  absent  except  blood  in  the  urine. 
Escape  of  urine  through  the  wound  can  take  place  only  when  the 
tract  of  the  latter  is  of  some  size  and  is  fairly  direct.  In  the  case  of  a 
small  wound,  such  as  would  be  made  by  a  twenty-two-calibre  pistol- 
ball,  the  tract  remains  direct  only  so  long  as  the  bladder  maintains 
the  same  degree  of  distention  as  at  the  moment  of  wounding.  In 
consequence  of  the  traumatism  the  urine  almost  immediately  escapes, 
and  as  the  bladder  contracts  the  opening  through  its  walls  no  longer 
lies  in  the  same  line  as  the  wound  of  the  parietes.  Moreover,  con- 
traction of  the  muscular  layers  makes  the  opening  through  their  sub- 
stance smaller,  and  the  mucous  membrane  has  a  tendency  to  pro- 
lapse, and  thus  occlude  the  wound  more  or  less  completely.  It  is 
only  when  the  wound  is  large  and  direct  that  this  pathognomonic 
sign  of  bladder-rupture  will  be  found. 

Though  tenesmus  and  the  frequent  voiding  of  a  small  quantity 
of  blood  or  bloody  urine  are  noted  as  a  rule,  these  symptoms  are  not 
invariably  excited.  There  may  be  absolute  inability  to  pass  anything 
from  the  bladder  by  the  urethra.  Introduction  of  a  probe  into  the 
bladder  through  the  wound  is  most  difficult  where  this  viscus  has 
changed  the  relation  of  its  wounded  wall  to  the  parietes,  though 
when  this  manoeuvre  is  successful,  and  when  the  probe  can  be  made 
to  strike  a  metal  catheter  carried  through  the  urethra  into  the  bladder, 
the  diagnosis  is,  of  course,  certain. 

Complications  of  Wounds  of  the  Bladder. — Immediately  following 
a  wound  of  the  bladder  hemorrhage  may  prove  a  serious  complica- 
tion ;  this,  when  so  violent  as  to  threaten  immediate  death,  nearly 
always  comes  from  the  large  vascular  trunks  in  the  pelvis,  and  not 
from  the  bladder-wall. 


404  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

In  a  few  hours  or  days  usually,  but  sometimes  in  cases  of  gun- 
shot wounds  not  until  after  one  or  two  weeks,  septic  peritonitis  may 
develop  from  intraperitoneal  wounds,  or  septic  cellulitis  from  extra- 
peritoneal wounds. 

The  remote  complications  are  fistulas,  which  may  pass  from  the 
bladder  to  the  vagina,  to  the  rectum,  or  to  the  external  skin  surface, 
and  concretions  which  may  be  formed  around  foreign  bodies,  such  as 
shot,  bullets,  fragments  of  the  garments,  or  splinters  of  bone. 

Diagnosis. — When  the  typical  symptoms  are  present  the  diagnosis 
is  easily  made.  When  these  symptoms  are  mainly  wanting  and  the 
presence  of  bloody  urine  and  a  wound  of  entrance  passing  in  the 
direction  of  the  bladder  are  the  only  signs  suggestive  of  the  lesion, 
examination  of  the  vesical  walls  by  means  of  a  sound  passed  through 
the  urethra,  aided  by  digital  exploration  through  the  rectum,  is  indi- 
cated. If  this  is  not  conclusive  in  its  results,  the  injection  and  imme- 
diate withdrawal  of  a  measured  quantity  of  dilute  antiseptic  solution 
may  prove  serviceable.  (See  Rupture  of  the  Bladder.)  If  this  does 
not  clear  the  diagnosis,  the  cystoscope  should  be  used,  the  bladder 
being  first  washed  clear  of  blood  by  irrigation  with  a  hot  antiseptic 
solution.  If  there  is  too  much  blood  in  the  bladder  to  allow  of  the 
use  of  the  cystoscope,  suprapubic  or  perineal  cystotomy  should  be 
performed  for  the  purpose  of  establishing  the  diagnosis,  the  choice 
of  operation  depending  on  the  position  of  the  external  wound. 

Prognosis. — This  depends  upon  whether  the  wound  is  extraperi- 
toneal or  intraperitoneal.  The  intraperitoneal  wounds  are  generally 
fatal  from  septic  peritonitis,  though  recovery  from  extravasated  urine 
becoming  encysted  and  absorbed,  or  from  closure  of  the  bladder- 
wound  by  adherence  of  bowel  or  omentum  to  its  peritoneal  aspect,  is 
possible. 

The  prognosis  of  extraperitoneal  wounds  is  much  more  favora- 
ble ;  in  the  absence  of  lesions  of  other  organs  the  large  majority  will 
recover.  Large,  clean,  direct  wounds,  and  wounds  inflicted  by  vul- 
nerating  bodies  entering  through  the  rectum  or  the  vagina,  usually 
drain  well.  The  outlook  for  gunshot  wounds  is  favorable  in  propor- 
tion to  the  freedom  with  which  urine  escapes  to  the  surface :  hence 
wounds  of  both  entrance  and  exit  are  less  serious  than  wounds  of  en- 
trance alone.  When  from  lack  of  thorough  drainage  extraperitoneal 
urinary  extravasation  and  cellulitis  occur,  the  symptoms  become  pro- 
nounced at  about  the  end  of  the  first  week. 

Treatment. — Since  extravasation  of  urine  and  subsequent  septic 
inflammation  are  the  main  dangers  incident  to  wound  of  the  bladder, 
the  most  important  indication  in  the  treatment  of  these  wounds  is  so 


IISrjUETES   AND   DISEASES    OF   THE    BLADDEE.  405 

to  provide  for  drainage  of  the  bladder  that  there  can  be  no  accumu- 
lation of  urine,  and  hence  no  condition  favoring  escape  of  this  fluid 
into  the  peritoneal  cavity  or  the  cellular  tissues. 

When  the  wound  is  intraperitoneal,  it  is  safe  to  assume  that  blood 
and  urine  have  already  entered  the  peritoneal  cavity.  Hence  imme- 
diate laparotomy  is  advisable,  followed  by  careful  toilet  of  the  perito- 
neum, closure  of  the  bladder-opening  by  suture,  closure  of  the  wound, 
and  either  suprapubic  or  perineal  drainage  or  permanent  catheteriza- 
tion. In  case  the  catheter  is  repeatedly  blocked  by  clots,  drainage 
by  incision  should  be  resorted  to  at  once.  The  urine  should  be 
rendered  antiseptic  by  the  administration  of  salol  and  boric  acid,  and 
ail  manipulations  must  be  conducted  with  the  utmost  cleanliness,  since 
the  wounded  bladder  is  strongly  predisposed  to  cystitis.  When  the 
wound  is  extraperitoneal,  suprapubic  or  perineal  drainage  is  indicated 
in  accordance  with  the  position  and  direction  of  the  wound.  Suture 
of  the  bladder  is  in  these  cases  rarely  practicable. 

Hemorrhage  is  treated  in  accordance  with  general  indications, — 
i.e.,  when  it  is  moderate,  injections  of  hot  astringent  antiseptics  (four 
per  cent,  solution  of  antipyrin)  may  be  employed,  together  with  the 
internal  administration  of  ergotin.  When  it  is  severe  and  persistent, 
it  may  require  packing,  the  application  of  forceps,  or  incision,  exposure 
of  the  bleeding  points,  and  ligation. 

Peritonitis  requires  immediate  laparotomy,  cleansing,  and  thorough 
drainage. 

Pelvic  cellulitis  is  treated  by  free  incisions  carried  deep  into  the 
perineum,  the  ischio-rectal  fossa,  over  the  pubis  into  the  space  of 
Retzius,  or  wherever  else  there  is  a  uro-purulent  infiltration. 

Contusion  of  the  Bladder.— Contusion  of  a  healthy  bladder 
without  rupture  of  its  walls,  though  proved  to  be  possible  by  a  few 
reported  cases,  is  probably  a  rare  form  of  injury.  Theoretically  it 
may  be  produced  by  the  causes  which  occasion  rupture  of  this  viscus, 
particularly  by  force  applied  to  the  anterior  abdominal  wall  when  the 
bladder  is  overdistended.  It  is  easy  to  imagine  that  if  this  force  is 
concentrated  it  may  cause  rupture  of  some  of  the  blood-vessels  lying 
in  or  beneath  the  mucous  membrane,  and  thus  may  cause  bleeding 
into  the  bladder. 

The  symptoms  of  this  injury  are  commonly  partial  or  complete 
retention,  tenesmus,  pain,  tenderness,  and  the  passage  of  blood-stained 
urine  and  of  clots.  Shock  should  be  moderate  or  altogether  wanting: 
It  is  possible,  particularly  in  a  bladder  which  has  been  the  seat  of 
disease,  that  bleeding  may  be  persistent  and  severe. 

The  diagnosis  is  of  importance,  since  this  injury  must  be  distin^ 


406  GEXIT0-UKI2s^AEY   DISEASES   AJS'D    SYPHILIS. 

guished  from  rupture.  Examination  witli  the  cystoscope  after  bleed- 
ing has  stopped  may  aid  in  excluding  rupture.  Most  reliance  can 
be  placed  on  injection  of  the  bladder  with  a  measured  quantity  of 
antiseptic  solution.  If  such  a  solution  is  forced  in  under  moderate 
pressure,  is  retained  for  two  or  three  minutes,  and  on  being  with- 
drawn by  a  catheter  is  found  to  have  lost  nothing  in  volume,  it  is  fair 
to  assume  that  there  is  no  breach  in  the  continuity  of  the  vesical 
wall. 

Treatment. — The  treatment  of  contusion  depends  entirely  on  the 
severity  of  the  symptoms.  When  bleeding  is  slight  and  there  is 
little  or  no  retention,  rest,  the  mouth  administration  of  urinary  anti- 
septics, and  the  control  of  tenesmus  and  pain  by  hot  baths,  hot 
abdominal  compresses,  and  opium  and  belladonna  suppositories  will 
fulfil  the  therapeutic  indications.  Even  when  there  is  some  obstruc- 
tion by  blood-clots  to  the  free  passage  of  urine,  it  is  well  to  abstain 
from  interference,  provided  dirty  instruments  have  not  been  passed 
into  the  bladder  previously  and  the  urine  is  sterile.  Should  retention 
become  well  marked,  a  sterile  full-sized  catheter  should  be  passed 
immediately,  under  the  antiseptic  cautions  described  when  treating  of 
retention,  and  the  clots  sucked  out  by  a  syringe,  or,  if  this  fails,  by 
means  of  the  large  evacuating  catheter  and  aspirator  of  a  litholapaxy 
instrument.  If  there  is  persistent  bleeding,  continuous  catheteriza- 
tion is  indicated.  Should  the  hemorrhage  be  profuse,  suprapubic 
cystotomy  should  be  performed ;  the  bleeding  points  can  then  be 
subjected  to  direct  treatment.  If  there  is  cystitis,  clots  should  be 
evacuated,  even  though  there  is  no  retention,  and  the  bladder  should 
be  irrigated  twice  daily  Avith  a  mild  antiseptic  solution  (silver  nitrate 
1  to  1000,  boric  acid  four  per  cent.,  or  Thiersch's  solution). 

Rupture  of  the  Bladder. — This  injury  may  be  either  intra- 
peritoneal or  extraperitoneal.  It  may  be  traumatic  or  pathological. 
So-called  idiopathic  cases  are  always  secondary  to  some  obstructive 
or  degenerative  factor.     It  usually  occurs  at  about  the  prime  of  life. 

The  causes  of  rupture  of  the  bladder  are  predisposing  and  exciting. 

Of  the  predisposing  causes  the  one  of  greatest  importance  is  the  con- 
dition of  distention.  Indeed,  it  is  difficult  to  imagine  how  the  empty 
viscus  can  be  ruptured  unless  there  are  extensive  concomitant  injuries. 

Alcoholism  is  a  predisposing  factor,  but  mainly  because  it  tends  to 
encourage  a  condition  of  over-distention  of  the  bladder,  from  the  fact 
that  it  simulates  the  kidneys,  and  so  obtunds  sensibility  that  the  desire 
to  micturate  is  not  noticed,  even  when  the  bladder  is  full. 

Fixation  of  the  bladder  by  pelvic  cellulitis,  degeneration  of  its 
walls  from  chronic  cystitis  or  atheroma,  and  disturbed  innervation, 
may  also  be  counted  as  predisposing  factors. 


INJUKIES   AND   DISEASES    OF    THE    BLADDEE.  407 

The  exciting  causes  are  fracture  of  the  pelvis,  separation  of  the 
pubic  symphysis,  violence  applied  either  directly  or  indirectly,  and 
muscular  strain.  Thus,  kicks  in  the  stomach,  falls  upon  the  ischium, 
and  the  straining  incident  to  parturition,  defecation,  urination,  or  lift- 
ing, have  caused  this  injury. 

Vesical  tension  from  acute  retention  of  urine,  or  from  injections 
practised  for  the  cure  of  cystitis  or  in  the  preparation  for  stone  oper- 
ations, may  cause  rupture  of  the  bladder  without  the  intervention  of 
strains  or  traumatism. 

Thus,  Dittel  performed  suprapubic  cystotomy  for  the  removal  of  a 
stone  in  a  child  aged  three.  The  bladder  was  injected  with  not  more 
than  three  ounces,  and  the  colpeurynter  contained  not  over  four 
ounces.  The  patient  perished  the  next  day  in  collapse,  with  symp- 
toms of  pericystitis.  In  the  posterior  wall  of  the  bladder  there  was 
found  a  tear  two-fifths  of  an  inch  in  length,  running  into  a  diver- 
ticulum.   This  caused  infiltration  of  the  pericystic  cellular  tissue. 

Pathological  rupture — that  in  which  the  bladder-walls  give  way 
from  over-distention,  without  the  intervention  of  force — is  usually  due 
to  an  enlarged  prostate,  since,  in  the  case  of  stricture,  the  urethra 
usually  ulcerates  posterior  to  the  seat  of  narrowing,  and  tension  is  re- 
lieved by  extravasation  of  urine  into  the  periurethral  cellular  tissues. 
It  is  probable  that  the  majority  of  cases  of  rupture  attributable  to 
muscular  strain  will  exhibit  pathological  changes  incident  to  urethral 
obstruction,  the  great  thickening  of  the  bladder-walls  occasioned  by 
such  obstruction  proving  no  safeguard  against  this  accident.  Cystitis 
in  these  cases  is  usually  complicated  either  by  ulceration  or  by  saccu- 
lation, thus  leaving  a  weak  portion,  which  may  rupture  from  slight 
causes. 

The  seat  of  rupture  may  be  either  intraperitoneal  or  extraperi- 
toneal. Fenwick  states  that  it  is  intraperitoneal  in  eighty-eight  per 
cent,  of  cases.  Ulmann  estimates  the  proportion  at  eighty-five  per 
cent.  The  greater  frequency  of  intraperitoneal  rupture  is  partly  due 
to  the  fact  that  the  area  covered  by  the  peritoneum  is  larger  and  is 
less  reinforced  by  the  pressure  of  closely  attached  surrounding  tissues. 
Moreover,  the  peritoneum  is  less  elastic  and  distensible  than  the  other 
coats,  and,  splitting  suddenly,  tears  the  muscular  and  mucous  coats 
with  it.  Direct  force  applied  to  the  hypogastric  region  usually  causes 
a  tear  of  the  upper  and  posterior  bladder-wall.  Ruptures  due  to 
fracture  of  the  pelvis  and  spontaneous  ruptures  are  apt  to  be  extra- 
peritoneal. The  rupture  is  commonly  single,  is  vertical  or  oblique 
in  direction,  and  when  intraperitoneal  the  peritoneal  aspect  is  most 
extensively  torn. 


408  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

Symptoms. — The  symptoms  of  rupture  of  the  bladder  are  a  sense 
of  something  giving  way  within  the  abdomen,  hypogastric  pain,  often 
agonizing,  constant  desire  to  urinate,  passage  of  a  few  drops  of  blood, 
or  of  blood-stained  urine,  or  failure  to  pass  anything,  and  severe 
shock. 

Following  these  symptoms,  under  appropriate  treatment  reaction 
usually  takes  place,  and  there  is  a  period,  varying  from  hours  to  days, 
during  which  the  patient  suffers  from  pain  and  tenderness  in  the  hypo- 
gastric region,  tenesmus,  and  a  constant  desire  to  micturate,  and 
passes  little  or  no  urine. 

Exploration  of  the  hypogastric  region  demonstrates  percussion  dul- 
ness  and  a  sense  of  resistance  closely  simulating  that  of  a  distended 
bladder,  while  rectal  examination  may  show  effusion  into  Douglas's 
cul-de-sac  or  the  cellular  tissues  lying  at  the  base  of  the  bladder. 
There  then  follows,  in  accordance  with  the  location  of  the. rupture, 
either  septic  peritonitis,  usually  terminating  fatally  in  five  days,  or  cel- 
lulitis, which  progresses  more  slowly,  and  is  attended  with  the  symp- 
toms of  septicaemia,  sometimes  running  a  course  of  several  weeks. 

Diagnosis. — The  diagnosis  of  rupture  of  the  bladder  is  founded 
upon  the  history  of  the  case,  the  symptoms  already  detailed,  notably 
shock,  tenesmus,  urgent  desire  to  micturate,  which  the  patient  cannot 
satisfy,  or  frequent  urination  and  the  passage  of  blood,  and  upon  the 
results  of  direct  examination.  All  the  subjective  symptoms  may  be 
excited  by  contusion  of  the  abdomen  ;  if  there  is  also  contusion  of  the 
bladder  the  urine  will  contain  blood.  The  bladder  may  be  ruptured 
without  exciting  a  single  characteristic  symptom.  Coates  reports  two 
cases  of  rupture  of  the  posterior  wall  in  which  the  lesion  was  not  sus- 
pected during  life,  no  signs  of  acute  peritonitis  having  developed.  The 
peritoneal  cavity  was  flooded  with  sterile  urine  ;  death  was  attributed 
to  absorption  of  the  urine  by  the  peritoneum,  with  a  consequent  toxic 
effect  upon  the  blood.  In  two  of  thirty-five  cases  collected  by  Nobe, 
the  urine  contained  no  blood.  In  both  cases  the  rupture  occurred  at 
the  vertex,  the  least  vascular  part  of  the  bladder. 

The  simplest  method  of  exploration  consists  in  the  passage  of  a 
thoroughly  sterilized  silver  catheter.  If  this  draws  off  bloody  urine 
and  clots,  the  probability  of  rupture  is  strong.  If  on  manipulation  of 
the  shaft  so  that  the  tip  is  made  to  traverse  the  inner  surface  of  the 
bladder  this  tip  repeatedly  catches  at  one  point,  and  apparently  can 
be  passed  through  the  bladder-wall,  so  that  it  can  be  felt  immediately 
below  the  skin  or  mucous  membrane  surface  by  palpation  in  the 
hypogastric  region  or  through  the  rectum,  there  can  no  longer  be 
doubt  about  the  existence  of  a  rupture. 


INJUEIES   AND   DISEASES   OF    THE    BLADDER.  409 

When  this  means  of  exploration  fails,  the  cystoscope  is  available, 
but  only  after  active  bleeding  has  ceased. 

The  injection  of  an  antiseptic  solution  is  by  no  means  an  infallible 
test,  since  even  an  extensive  rupture  may  so  quickly  close  by  inflam- 
matory adhesion  that  a  solution  injected  with  gentle  pressure  fails  to 
break  this  down,  and  the  total  quantity  injected  is  at  once  returned. 

Weir  states  that  this  injection  method  (Cabot's)  is  made  more 
reliable  by  several  repetitions,  enough  tluid  being  driven  in  each  time 
markedly  to  distend  the  bladder.  The  method  is  rendered  still  more 
serviceable  by  preceding  the  injection  by  a  careful  digital  examination 
of  the  rectum,  followed  by  the  insertion  and  distention  of  the  Barnes 
bag.  The  bladder  is  then  injected  with  a  known  volume  of  fluid.  If 
there  results  rapid  increase  in  pelvic  tumor  and  dulness,  as  detected 
by  suprapubic  examination,  this  must  be  due  either  to  the  distended 
bladder  or  to  extra vasated  fluid.  In  the  latter  event  failure  to  recover 
by  catheterization  all  the  fluid  injected  will  show  the  presence  of  an 
extraperitoneal  rupture.  In  case  there  is  developed  no  suprapubic 
dulness,  but  all  the  fluid  is  not  recovered,  there  must  be  either  an 
intraperitoneal  or  a  subperitoneal  postero-inferior  rupture.  In  the 
latter  case  withdrawal  of  the  Barnes  bag  and  a  second  digital  exam- 
ination of  the  rectum  will  show  the  increase  of  extravasation.  The 
injection  of  air  is  not  more  reliable  as  a  means  of  diagnosis  than  is 
that  of  water. 

In  case  of  doubt  there  should  be  no  hesitation  in  performing 
either  a  subpubic  or  a  perineal  cystotomy  and  thoroughly  exploring 
the  bladder  by  the  finger  and  by  sight.  Always,  when  instruments  are 
used  for  diagnostic  purposes,  the  principles  of  surgical  cleanliness 
must  be  minutely  observed,  and  if  a  rupture  is  found,  operation  should 
be  performed  at  once. 

Prognosis. — Rupture  of  the  bladder  results  fatally  in  a  large  pro- 
portion of  cases,  and  the  prognosis  is  particularly  grave  when  the  rent 
is  complicated  by  fracture  of  the  pelvis  and  when  it  is  intraperitoneal, 
death  resulting  in  the  great  majority  of  these  cases  in  the  first  five  days. 
Spontaneous  recovery,  though  possible,  is  so  rare  as  to  constitute  a 
surgical  curiosity.  The  extraperitoneal  tears  are  somewhat  less  fatal, 
but  in  the  absence  of  proper  surgical  intervention  the  majority  of 
these  perish.  The  prognosis  is  undoubtedly  better  to-day,  when 
antiseptics  are  generally  employed  in  the  treatment  of  bladder-lesions, 
than  in  the  former  septic  period.  The  urine  when  first  extravasated 
from  a  healthy  bladder  is  a  sterile  fluid  and  does  not  cause  inflamma- 
tion. Hence,  if  not  infected  by  the  use  of  dirty  instruments,  it  under- 
goes changes  slowly. 


410  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

The  conditions  for  germ-growth  are,  however,  so  favorable  that 
the  slightest  infection  is  followed  by  rapid  and  extensive  suppuration. 
Of  the  cases  operated  on  within  the  first  twelve  hours,  the  mortality- 
is  about  thirty-eight  per  cent.,  from  twelve  to  twenty-four  hours 
seventy  per  cent.,  after  this  about  seventy-three  per  cent. 

Nobe  reports  thirty-five  cases,  twenty-one  of  which  were  operated 
upon  and  eighteen  of  these  recovered. 

Jones  collected  fifty-four  cases  of  intraperitoneal  rupture  of  the 
bladder  treated  by  suture,  with  a  mortality  of  forty-eight  per  cent. 
The  cases  are  divided  into  two  groups,  previous  to  and  since  1893. 
In  the  former  were  thirty-two  cases  with  a  mortality  of  sixty-three 
and  one-half  per  cent.,  while  since  1893  twenty-two  cases  have  given 
a  mortality  of  only  twenty-seven  and  one-half  per  cent. 

Causes  of  death  are  most  frequently  peritonitis  (seventeen  of 
twenty-six  cases),  shock,  and  hemorrhage. 

Schlanger  notes  ten  recoveries  out  of  twenty-two  operations  for 
intraperitoneal  rupture.  Seven  out  of  ten  were  cured  when  the 
rupture  was  extraperitoneal. 

Treatment. — If  the  wound  is  intraperitoneal,  an  immediate  lapa- 
rotom.y,  thorough  cleansing  of  the  peritoneal  cavity,  and  closure  of 
the  bladder  by  suture  are  indicated.  It  is  important  that  this  opera- 
tion should  be  performed  immediately, — that  is,  before  the  beginning 
of  peritonitis.  When  exploration  fails  to  show  whether  the  rent  is 
intraperitoneal  or  extraperitoneal,  suprapubic  cystotomy  should  be 
performed  and  a  diagnosis  thus  made ;  if  further  room  is  required, 
the  lateral  incisions  of  Trendelenburg,  or  even  symphyseotomy,  may 
be  necessary. 

The  suture  by  which  intraperitoneal  bladder-wounds  are  closed  is 
applied  exactly  as  is  the  Czerny-Lembert  suture  in  dealing  with 
wounds  of  the  gut :  that  is,  the  stitches  are  placed  about  six  to  an 
inch ;  the  first  row,  preferably  of  fine  sterile  catgut,  closes  the  rent, 
each  stitch  including  all  but  the  mucous  coat  of  the  bladder  ;  this 
line  of  union  is  then  turned  in  by  a  second  row  of  Lembert  sutures ; 
the  needle  is  passed  in  and  out  on  one  side  of  the  wound  vertical  to 
its  length,  and,  including  the  serous  and  muscular  coats,  it  crosses  the 
wound  and  is  passed  in  and  out  as  before  on  the  opposite  side.  If 
these  sutures  are  knotted  the  peritoneal  surfaces  are  brought  in  appo- 
sition, and  inflammatory  agglutination  takes  place  in  less  than  twenty- 
four  hours.  When  the  sutures  have  been  properly  applied  in  healthy 
non-infected  tissue  there  is  no  tendency  to  the  reopening  of  the 
wound.  ,  To  make  sure  that  the  wound  has  been  thoroughly  closed, 
the  bladder  should  be  moderately  distended  with  mild  antiseptic  solu- 


INJURIES    AND    DISEASIiS   OF    THE    BLADDER.  411 

tion ;  if  apposition  is  perfect  there  will  be  no  leakage.  The  perito- 
neum should  be  thoroughly  cleaned  of  clots  and  of  extravasated  urine. 
This  is  best  accomplished  by  dry  sponging.  When  septic  peritonitis 
has  already  been  excited,  hot  irrigation  with  normal  saline  solution  is 
indicated,  followed  by  drainage-tubes,  or  the  antiseptic  tampon  in 
accordance  with  Mickuhcz's  method.  In  large,  irregular,  contused  or 
lacerated  wounds  of  a  diseased  bladder  the  line  of  suture  cannot  be 
trusted.  The  wound  should  be  rapidly  closed  by  a  continuous,  catgut 
suture,  and  gauze  drainage  rnnning  down  to  the  region  of  injury 
should  be  continued  for  several  days. 

When  suprapubic  cystotomy  has  been  performed  for  exploratory 
purposes  and  the  rent  is  found  to  be  extraperitoneal,  it  should  be 
thoroughly  cleansed  and  closed  by  interrupted  suture.  The  results, 
so  far  as  the  closure  of  the  wound  is  concerned,  are  not  so  satisfactory 
as  those  obtained  by  the  suture  of  intraperitoneal  openings.  Hence 
a  drainage-tube  or  a  gauze  tampon  should  lead  to  the  seat  of  injury, 
thus  providing  for  the  free  escape  of  urine  in  case  the  sutures  should 
give  way. 

The  after-treatment  of  operation  for  bladder  rupture  consists  in 
the  employment  of  continuous  catheterization  for  from  three  to  eight 
days,  after  which  the  patient  is  allowed  to  urinate.  The  method  of 
using  continuous  catheterization  is  the  same  as  that  described  under 
the  treatment  of  retention  from  prostatic  enlargement.  Extraperito- 
neal ruptures  are  treated  by  permanent  catheterization,  supple- 
mented by  antiseptic  irrigation  of  the  bladder  practised  night  and 
morning.  If  the  surgeon  distrusts  the  permanent  catheter,  as  he 
should  do  in  most  cases  with  extensive  and  comphcated  wounds, 
suprapubic  siphon  drainage  or  the  insertion  of  a  tube  through  the 
perineum  is  indicated. 

Pain,  particularly  that  referred  to  the  rectum  and  running  down 
the  thighs,  and  rigors  and  fever,  point  to  extravasation  and  cellulitis, 
and  indicate  either  a  suprapubic  or  a  perineal  cystotomy.  The  supra- 
pubic operation  is  preferable  unless  oedema,  tenderness,  and  swelling 
show  that  the  perineum  is  the  seat  of  infiltration. 


CHAPTER   XI. 

CYSTITIS. VESICAL    TUBERCULOSIS. VESICAL    SYPHILIS.— VESICAL    FISTULA. 

Cystitis  is  an  inflammation  of  the  bladder  due  to  germ-infection. 

The  sudden  acute  congestion  due  to  retention,  chilling,  irritating 
conditions  of  the  urine,  or  foreign  body,  is  not  considered  as  a  true 
inflammation,  since,  unless  there  is  added  to  this  congestion  germ- 
infection,  the  condition  is  transitory,  and  is  attended  by  no  lesions, 
barring  vascular  engorgement.  Yet  while  the  congestion  lasts  the 
symptoms,  with  the  exception  of  pus  and  micro-organisms  in  the 
urine,  are  identical  with  those  of  acute  cystitis. 

Classification. — Cystitis,  in  accordance  with  its  clinical  course,  may 
be  acute  or  chronic.  From  the  pathological  stand-point  the  disease 
may  be — 

1.  Superficial  or  catarrhal. 

2.  Interstitial. 

3.  Pericystic. 

Further  subdivisions,  sufficiently  indicated  by  their  names,  are 
pseudomembranous  cystitis  and  gangrenous  cystitis. 

Etiology. — The  causes  of  cystitis  are  predisposing  and  exciting. 
The  predisposing  causes  are  those  which  favor  congestion  and  reten- 
tion, the  latter  condition  implying  the  former,  since  an  over-fufl 
bladder  is  always  congested.  A  normal  bladder  containing  normal 
urine  which  is  evacuated  at  proper  intervals  is  not  readily  infected. 
Even  though  germs  be  carried  directly  into  its  cavity,  by  dirty  instru- 
ments for  instance,  the  resistance  of  the  healthy  tissues  is  sufficient 
to  pre\  ent  penetration  and  multiplication  of  micro-organisms. 

The  causes  of  vesical  congestion  are — 1.  Retention  of  urine.  The 
vesical  congestion  is  in  proportion  to  the  acuteness  of  the  retention  : 
hence  a  sudden  distention  of  the  bladder  is  a  more  favoring  factor  in 
the  development  of  cystitis  than  is  a  gradual  accumulation  of  urine. 

2.  Trauma.  This  may  be  due  to  jar,  strain,  contusion  or  laceration, 
rough  instrumentation,  or  bruising  by  a  stone  or  other  foreign  body. 

3.  Muscular  contractions  abnormally  frequent  or  prolonged.  These 
may  be  excited  reflexly  by  lesions,  irritations,  or  inflammations  of  the 
rectum,  sexual  organs,  kidneys,  or  urethra,  or  may  be  due  to  hypersen- 
sitiveness  of  the  micturition  centre,  to  habit,  to  polyuria,  or  to  acute 

412 


CYSTITIS.  413 

congestion.  4,  Abnormal  conditions  of  the  urine.  If  the  urine  is 
essentially  changed  in  any  of  its  characteristics,  it  will  eventually  act 
as  an  irritant  to  the  vesical  mucosa.  If  it  is  strongly  acid,  markedly 
alkahne,  or  of  very  low  or  very  high  specific  gravity,  it  occasions  con- 
gestion. Thus,  the  gouty  and  rheumatic,  dyspeptics  suffering  from 
oxaluria,  phosphaturia,  or  other  urinary  changes,  diabetics,  cachectics 
with  haematuria,  persons  who  have  been  severely  burned,  and  those 
who  have  ingested  overdoses  of  drugs  such  as  cantharides,  turpentine, 
the  balsams,  alcohol,  or  arsenic,  are  predisposed  to  cystitis  by  vesical 
congestion.  5.  Tumors  and  calculi.  It  should  be  borne  in  mind  that 
tumors  and  calculi  do  not  in  themselves  cause  cystitis,  but  merely 
predispose  to  its  development  by  the  congestion  which  their  presence 
occasions,  and  by  the  admixture  of  blood  with  the  urine,  thus  rendering 
it  alkaline  and  peculiarly  rich  as  a  culture  fluid.  6.  Surface  chilling, 
as  from  getting  the  feet  wet  or  sitting  on  the  damp  ground,  may  cause 
a  sudden  and  very  marked  congestion  of  the  bladder,  though  never 
a  true  cystitis.  7.  Prolonged  sexual  excitement  or  excess  in  sexual 
intercourse  is  a  potent  factor  in  the  production  of  bladder  hyperaemia. 
S.  Cardiac  weakness,  venous  obstruction,  and  atheromatous  degener- 
ation of  the  vessels  are  factors  often  operative  in  the  aged,  which 
when  combined,  as  is  often  the  case,  with  an  enlarged  and  inflamed 
prostate,  and  hence  with  retention  of  urine,  make  the  development  of 
cystitis  nearly  certain.  9.  Lesions  of  the  central  nervous  system  by 
destroying  vaso-motor  control  and  favoring  retention  of  urine  strongly 
favor  the  development  of  cystitis. 

Congestion  of  the  bladder  is,  then,  the  condition  which  most  pre- 
disposes to  cystitis.  When  to  the  congestion  is  added  retention,  par- 
ticularly if  of  an  alkaline  and  albumen-  or  blood-containing  urine,  the 
most  favorable  conditions  for  germ-infection  are  present.  It  is  clear 
that  several  of  the  causes  of  acute  congestion  may  be  operative  at  the 
same  time :  thus,  during  acute  fever  there  may  be  atonic  retention 
of  urine  which  is  irritating  from  the  pyrexia ;  or  after  spinal  injury 
there  may  be  vaso-motor  dilatation,  combined  with  retention  from 
detrusor  paresis. 

The  exciting  cause  of  cystitis  is  local  infection.  This  infection  is 
commonly  due  to  catheterization  and  urethritis.  Infection  byway  of 
the  ureters  may  also  take  place,  but  probably  not  unless  the  kidneys 
are  diseased,  though  it  has  been  demonstrated  that  apparently  healthy 
kidneys  may  eliminate  pyogenic  organisms. 

Pericystic  suppuration  may  also  occasion  local  bladder-infection 
by  destroying  the  bladder-wall  and  discharging  pus  into  its  cavity. 

Wreder  has  proved  that  infection  is  not  always  due  to  catheteriza- 


414  GENITO-URINARiT    DISEASES   AND   SYPHILIS. 

tion  or  to  extension  of  inflammation  from  ttie  urethra.  The  microbes 
may  enter  the  bladder  from  the  kidneys,  by  the  agency  of  the  blood- 
or  lymph-channels,  or  they  may  pass  directly  from  the  rectum,  this 
direct  passage  being  particularly  liable  to  take  place  in  cases  of  con- 
stipation, inflammation,  hemorrhoids,  tumors  of  the  rectum,  or  lesions 
of  the  prostate. 

Normal  urine  is  sterile.  In  the  urine  of  cystitis  have  been  found 
a  great  number  of  organisms,  many  of  them  without  pyogenic  action. 
Of  the  micro-organisms  which  occasion  cystitis  the  colon  bacillus  is 
the  one  most  frequently  found.  After  this  come  the  staphylococci 
and  streptococci  of  ordinary  pus  and  the  bacillus  proteus  vulgaris. 
It  seems  clear  that  the  gonococcus  may  invade  a  part  or  even  the 
whole  of  the  trigonum,  but  there  is  evidence  that  the  remaining  vesical 
mucous  membrane  is  at  least  partially  immune  to  its  attack.  Cases  of 
true  bladder-inflammation  traceable  to  gonorrhoea  are  usually  due  to 
mixed  infection.  This  is  also  true  of  post-typhoid  cystitis,  though 
cases  are  reported  in  which  the  urine  contained  pure  typhoid  cultures. 

The  tubercle  bacilli  wih  be  discussed  under  the  head  of  Tubercu- 
losis of  the  Bladder.  In  themselves  they  are  not  able  to  cause  general 
cystitis,  but  they  strongly  predispose  to  mixed  infection. 

Germs  exert  their  injurious  action  upon  the  bladder-tissue  either 
directly  or  through  their  ptomaines.  The  inflammation  they  produce 
is  increased  by  the  ammoniacal  fermentation  of  the  urine  which  they 
bring  about.  This  fermentation  is  due  to  the  decomposing  action  of 
microbes  upon  urea,  ammonium  carbonate  being  formed.  This  con- 
verts the  pus  into  a  ropy,  gelatinous  mass,  renders  the  urine  markedly 
alkaline,  and  makes  it  thick,  foul,  and  ammoniacal.  Practically  all 
the  pyogenic  germs  and  many  others  found  in  the  urine  of  cys- 
titis produce  this  ammoniacal  fermentation.  As  a  result  the  urine  be- 
comes intensely  irritating :  hence  the  cystitis  is  aggravated.  It  must, 
however,  be  borne  in  mind  that  this  fermentation  is  the  result  of 
cystitis,  and  not  its  cause. 

A  condition  essential  to  the  formation  of  ammoniacal  urine  is  re- 
tention, which  must  at  least  be  partial.  Even  when  retention  is  present 
this  fermentation  takes  place  to  a  minor  degree  or  not  at  all  when  the 
urine  is  acid  and  contains  but  little  urea  and  when  the  pus-formation 
is  slight.  Retention  of  an  abundant  purulent  secretion  and  secretion 
of  urine  rich  in  urea  are  most  favorable  for  this  fermentation.  It  is 
absolutely  diagnostic  of  cystitis,  though  care  must  be  taken  to  see  that 
the  urine  has  undergone  this  fermentation  at  the  time  of  passing,  since 
under  certain  conditions  it  may  take  place  very  shortly  afterwards. 

Cystitis  has  for  its  seats  of  predilection  the  trigonum,  the  urethral 


CYSTITIS.  415 

orifice,  and  the  region  about  the  ureteral  openings.  It  is  in  these 
regions  particularly  that  the  most  pronounced  lesions  are  usually 
found,  even  though  the  entire  vesical  mucous  membrane  is  involved. 

Superficial  or  catarrhal  cystitis  in  its  acute  form  is  characterized 
by  a  reddened,  oedematous,  ecchymotic  mucous  membrane  the  vessels 
of  which  are  markedly  engorged.  Erosions  or  distinct  ulcerations 
may  develop.  Exceptionally  shreds  of  necrotic  mucous  membrane 
are  passed.  The  urine  is  usually  acid,  and  contains  pus  and  much 
bladder  epithelium. 

When  superficial  cystitis  becomes  chronic,  reddening  of  the  thick- 
ened mucous  membrane  is  no  longer  pronounced.  Indeed,  this  may 
assume  a  yellowish  hue  with  prominent  veins  and  areas  of  exfoUation 
colored  gray-white  by  thin  layers  of  pus  or  urinary  salts.  From  the 
oedematous  and  congested  mucous  membrane  small  polyps  may 
grow,  and  the  inner  surface  of  the  bladder  is  often  trabeculated  from 
muscular  hypertrophy. 

The  urine  is  generally  alkaline ;  when  markedly  so  from  ammo- 
niacal  fermentation,  there  is  often  found  overlying  the  mucous  mem- 
brane a  dirty-whitish  deposit  of  muco-pus. 

Interstitial  cystitis  exhibits  the  mucous  membrane  lesions  of  a 
superficial  inflammation.  The  inflammation  extends  more  deeply, 
however,  involving  particularly  the  connective  tissue,  but  not  entirely 
sparing  the  muscular  fibres.  From  the  inflammatory  infiltration  the 
folds  of  the  mucosa  become  prominent,  causing  ridges  to  be  formed, 
which  are  readily  felt  on  exploration  by  a  sound.  Small  abscesses 
develop  in  the  submucous  connective  tissue  or  in  the  muscular  coats. 
These  abscesses  commonly  open  into  the  vesical  cavity,  leaving  diver- 
ticula which  are  slow  to  heal.  Exceptionally  such  abscesses  extend 
outward,  involving  the  perivesical  tissues  and  resulting  in  localized 
pelvic  cellulitis  or  in  peritonitis.  If  the  active  disease  is  arrested, 
organization  and  cicatrization  take  place,  producing  more  or  less  dis- 
tortion and  contraction,  sometimes  sufficient  to  lessen  greatly  the 
vesical  capacity. 

Alexander  describes  a  nodular,  glandular  cystitis  characterized  by 
the  appearance  of  small  nodules  disseminated  over  the  bladder  sur- 
face resembling  tubercles.  These  nodules  are  made  up  of  vascular 
lymphatic  tissue  arranged  in  circumscribed  foci.  He  states  that  cys- 
titis complicated  by  these  nodules  is  extremely  chronic,  and  subject 
to  relapses,  and  that  pain  and  hemorrhage  are  pronounced. 

Membranous  cystitis,  variously  described  as  exfoliative,  croupous, 
diphtheritic,  and  desquamative,  is  characterized  by  the  discharge 
through  the  urethra  or  through  a  wound  of  the  bladder  of  flakes, 


41Q  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

masses,  or  complete  moulds  of  the  bladder,  made  up  of  tough, 
fibrinous,  structureless  membrane  containing  the  remains  of  broken- 
down  epithelium. 

Stein  states  that  of  fifty  reported  cases,  forty-five  occurred  in 
women,  and  mostly  in  connection  with  labor  or  with  serious  uterine 
troubles.  The  pathology  seems  to  vary  somewhat  in  different  cases^ 
Thus,  Cabot,  in  practising  suprapubic  cystotomy,  peeled  off  a  thick 
membrane  composed  almost  entirely  of  epithelium.  Adami  holds  that 
true  exfoliative  cystitis  is  practically  a  necrosis  of  the  inner  layers  of 
the  bladder. 

Gangrenous  cystitis  is  characterized  by  sloughing  of  the  mucous 
and  muscular  coats  of  the  bladder.  It  is  occasionally  noted  in  acute 
septic  processes,  in  cancer  of  the  bladder,  and  as  a  sequel  to  extensive 
trauma. 

Pericystitis  is  separately  considered. 

Symptoms  of  Cystitis. — There  are  no  subjective  symptoms  which 
point  exclusively  to  cystitis, — pain,  frequent  micturition,  and  pus  in 
the  urine,  symptoms  usually  considered  diagnostic  of  bladder-inflam- 
mation, being  present  when  the  prostatic  urethra  alone  is  involved. 

The  symptoms  of  cystitis  are — 1 ,  pyuria ;  2,  frequent  urination ; 
3,  pain  ;  4,  muscular  spasm  ;  5,  hsematuria  ;  6,  fever. 

Of  these  symptoms  pyuria  is  the  only  one  which  is  constant. 

Pyuria. — This  symptom  is  constant,  and  may  be  pathognomonic 
of  cystitis.  With  pus  there  is  frequently  found  blood,  and  there  is 
always  a  superabundance  of  mucus  and  bladder  epithelium.  When 
the  urine  is  acid,  there  settles  from  it  on  standing  a  white  sediment  of 
pus,  and  over  this  a  cloud  of  mucus.  When  the  urine  is  neutral  or 
alkaline,  particularly  when  ammoniacal  decomposition  has  taken  place, 
there  is  often  a  viscid,  ropy  deposit  of  muco-pus.  In  chronic  cases 
micturition  may  terminate  by  the  expulsion  of  almost  pure  muco-pus. 

Microscopical  examination  of  the  sediment  shows  abundant  blad- 
der epithelium,  pus,  often  blood,  micro-organisms,  and  in  alkaline  urine 
crystals  of  the  triple  phosphates. 

Frequent  Urination. — This  symptom  develops  partly  because  the 
bladder-walls  are  abnormally  sensitive  to  tension,  partly  because  the 
prostatic  urethra  is  inflamed  and  hypersensitive.  Frequent  urination 
is  aggravated  by  the  erect  posture,  by  bodily  activity,  by  jolting  or. 
jarring,  and  by  any  of  the  causes  which  tend  to  increase  congestion 
of  the  prostatic  urethra.  At  times  the  patient  is  forced  to  micturate 
every  few  minutes,  and  is  absolutely  unable  to  retain  his  water  when 
the  desire  is  felt ;  usually,  however,  it  can  be  retained  one  or  two 
hours. 


CYSTITIS.  417 

The  frequent  urination  which  so  often  accompanies  chronic  cys- 
titis, particularly  when  there  is  a  mechanical  obstruction  to  the  free 
passage  of  urine,  may  occasion  an  enormous  hypertrophy  of  the 
muscular  trabecules,  with  a  sacculation  of  the  weaker  portions  of  the 
vesical  walls  lying  between  these  interlacing  fibres.  Bladders  thus 
affected  are  most  difficult  to  cleanse  of  the  ammoniacal  urine. 

When  there  is  frequent  urination  and  much  straining,  there  may  be 
some  kidney  albuminuria  due  to  congestion  of  these  organs.  Usually 
the  quantity  of  albumen  in  the  urine  is  proportionate  to  the  amount 
of  blood  and  pus  which  it  contains.  Exceptionally  in  chronic  cases 
there  may  be  a  leakage  through  patches  denuded  of  the  surface  epi- 
thelium. 

Pain. — This  in  the  acute  cases  is  constant,  with  exacerbations 
taking  the  form  of  intense  burning,  with  irresistible  desire  to  pass 
water  and  violent  straining  (tenesmus).  It  is  usually  aggravated  by 
the  act  of  micturition,  and  is  more  or  less  relieved  after  the  bladder 
is  emptied.  Exceptionally,  as  in  the  case  of  stone  and  acute  gonor- 
rhoeal  prostato-cystitis,  the  pain  is  most  intense  after  micturition.  It 
is  felt  in  the  prostate  and  bladder,  and  radiates  from  there  to  the 
hypogastric  region,  the  sacrum,  the  rectum,  the  end  of  the  penis,  and 
down  the  inner  surfaces  of  the  thighs.  In  very  acute  cases  when 
there  is  prostato-cystitis  the  patient  is  compelled  almost  constantly  to 
make  violent  and  most  painful  straining  efforts  at  urination,  with  the 
evacuation  of  but  a  few  drops  of  blood-stained  water  at  a  time 
(strangury). 

Muscular  Spasm. — As  a  result  of  inflammation  reflex  excitability 
is  markedly  exalted.  It  is  to  the  overaction  of  the  sphincter  muscles 
that  much  of  the  pain  in  cystitis  is  due.  These  are  thrown  into  tonic 
contraction,  or  sphincterismus,  thus  increasing  congestion  and  exciting 
pain,  very  much  as  do  the  anal  sphincters  in  acute  proctitis.  By  their 
tonic  contraction  they  resist  the  attempts  of  the  detrusors  to  empty 
the  bladder,  yielding  only  after  long  effort,  and  then  but  partly,  thus 
occasioning  strangury.  Or  the  contraction  may  be  so  obstinate  that 
there  is  complete  retention  of  urine.  Very  frequently  the  tonic  spasm 
is  replaced  by  clonic  contractions,  which  suddenly  shut  off  the  stream 
when  it  is  started,  especially  when  the  last  few  drops  are  being  voided. 
From  the  closely  connected  nerve-supply,  the  sphincter  ani  some- 
times participates  in  this  tonic  contraction,  thus  adding  to  the  distress. 

Hcematuria. — The  passage  of  almost  pure  blood,  especially  when 
it  comes  at  the  end  of  urination,  is  characteristic  of  inflammation  of 
the  prostatic  urethra  rather  than  of  cystitis.  After  micturition  is  com- 
pleted the  bleeding  may  still  continue  from  this  region  and  flow  back 

27 


418  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

into  the  bladder,  rendering  the  urine  alkaUne  and  predisposing  it 
to  ammoniacal  fermentation,  with  marked  aggravation  of  the  cystitis. 
From  the  bladder- walls  in  hyperacute  cases  there  is  usually  some, 
bleeding.  This  is  slight,  and  the  blood  is  intimately  mixed  with  the 
urine. 

Fever. — In  the  beginning  of  an  acute  cystitis,  fever  and  the  asso- 
ciated symptoms  of  depression,  nausea  and  constipation,  are  frequently 
observed. 

Fever  is,  however,  by  no  means  an  invariable  symptom.  When 
it  reaches  a  high  grade,  and  is  prolonged  and  is  paroxysmal  in  type,  it 
may  be  taken  as  a  sign  that  cystitis  is  not  the  only  cause.  In  these 
cases  a  careful  examination  usually  shows  that  either  the  prostate  or 
the  kidneys  are  seriously  involved. 

Diagnosis. — Frequent  urination,  pain,  and  pus  in  the  urine  are  of 
themselves  not  enough  to  make  the  diagnosis  of  cystitis  complete. 

.  In  cases  of  chronic  inflammation  there  may  be  no  symptoms  ex- 
cept pyuria.  When,  together  with  some  or  all  of  the  symptoms  giv^n 
above,  the  bladder  is  tender  on  suprapubic  and  rectal  palpation, 
whfen  .the  urine  passed  in  three  portions  shows  greatest  pus-tur- 
bidity in  the  last,  when  the  flat  bladder  epithelium  is  very  abundant, 
when  intravesical  injections  show  that  the  bladder  is  hypersensitive 
to; tension,  and  when  the  urine  at  the  time  of  being  passed  is  ropy  and 
ammoniacal,  the  diagnosis  of  cystitis  can  be  made  confidently. 
;.  In  many  cases  these  characteristic  features  of  bladder-inflamma- 
tion are  not  present.  The  diagnosis  may  then  be  made  by  cystoscopic 
ex'akhination  ;  or  a  soft  catheter  with  a  central  terminal  opening  and 
provided  with  a  broad  elastic  hollow  flange  just  behind  this  opening 
and  so  stretched  over  a  carrier  that  the  flange  is  obliterated  may  be 
introduced  into  the  bladder.  On  withdrawing  the  carrier  the  elas- 
ticity of  the  rubber  causes  the  flange  to  resume  its  shape.  The  cath- 
eter is  then  drawn  out  till  the  flange  catches  against  the  internal 
vesical  sphincter,  and  is  secured  in  place  by  a  small  weight  attached 
to  its  free  end.  The  bladder  is  thoroughly  washed  out  with  normal 
salt  solution,  and  the  catheter  is  lefl:  in  place  for  an  hour,  the  urine 
which  flows  through  it  being  collected.  It  is  obvious  that  any  pus 
found  in  this  urine  must  come  from  the  bladder  or  the  kidneys,  since 
the  flange  effectually  shuts  off  the  prostatic  urethra  from  the  bladder. 

Prognosis  of  Cystitis. — Provided  there  is  no  lesion  which  tends  in- 
definitely to  prolong  vesical  congestion,  the  prognosis  of  acute  cystitis 
is  favorable.  The  inflammation  which  frequently  accompanies  stone 
or  tight  stricture  of  the  urethra,  or  even  enlarged  prostate,  can  be 
completely  cured  by  removal  of  the  exciting  cause.     Cystitis  due  to 


-  -.     -     CYSTITIS.  419 

gonorrhoea  or  rough  instrumentation  usually  runs  a  rapid  and  favor- 
able course.  It  often  happens,  however,  that  some  infection  of  the 
mucosa  remains,  which  is  stimulated  to  renewed  activity  whenever, 
normal  emptying  of  the  bladder  is  interfered  with,  or  when  sexual  or 
alcoholic  excess  or  intercurrent  disease  causes  pelvic  congestion  and 
irritation.  The  cure  is  probably  more  often  relative  than  absolute, 
since  it  is  considered  established  when  micturition  is  accomplished 
normally  and  when  the  urine  is  apparently  clear. 

The  final  conclusive  proof  of  cure  should  be  founded  upon  the 
results  of  microscopic  examination. 

If  the  centrifuged  sediment  of  twenty-four  hours'  urinary  secretion 
is  found  to  be  free  from  pus,  the  patient  may  be  considered  cured.. 
If,  on  the  contrary,  pus  is  found,  even  though  it  be  in .  small  quan- 
tities, perhaps  scarcely  enough  to  form  shreds,  some  focus  of  infection 
still  remains,  and  is  liable  to  light  up  an  acute  inflammation  Under: 
favoring  circumstances. 

The  prognosis  of  chronic  cystitis  is  less  favorable  than  that  of  the 
acute.  It  is  not,  however,  absolutely  bad.  Surgical  treatment  of 
stricture  and  enlarged  prostate  shows  that,  after  removal  of  the  pre- 
disposing cause,  bladders  which  have  been  inflamed  for  years,  and 
which  are  greatly  dilated  and  atonic,  may  regain  power  and  may 
apparently  become  healthy.  This  was  considered  the  exception,  at 
least  in  prostatics,  until  recently.  In  fifty-two  per  cent.,  however,: 
of  a  considerable  number  of  cases  of  prostatic  overgrowth,  subjected! 
to  castration,  the  symptoms  of  a  previously  intractable  cystitis  disap-, 
peared,  so  that  a  more  favorable  view  may  now  be  taken  of  the  pros- 
pects of  such  patients.  As  a  rule,  though  the  active  symptoms  may 
be  subdued  or  may  entirely  disappear,  some  suppuration  persists. 

It  may  happen  that  from  infiltration  of  the  bladder- walls,  followed 
by  fibroid  change  and  contraction,  the  vesical  cavity  becomes  greatly 
reduced,  ,so  that  the  bladder  can  contain  but  a  few  ounces  at  a  time. 
More  frequently,  particularly  in  the  case  of  prostatics,  there  is  dila- 
tation with  an  incurably  thickened  suppurating  mucous  membrane. 

In  its  relation  to  involvement  of  the  kidneys,  and  consequently  to 
the  life  of  the  patient,  the  prognosis  of  acute  and  chronic  cystitis  is 
somewhat  different. 

Lipowski  states  that  the  conditions  favoring  ascending  infection 
are  moderate  retention  and  a  strong,  irritable  bladder,  which  drives 
urine  back  into  the  ureter  at  the  moment  the  orifice  of  this  canal  is 
opened  to  expel  its  contents.  These  conditions  are  fulfilled  in  cases 
of  stricture,  hypertrophied  prostate,  acute  inflammation,  and  spastic 
affections   during   the   first   period   of  cystitis.      The   inflammation 


420  GENITO-UEINAET   DISEASES   AXD   SYPHILIS. 

markedly  increases  the  irritability  of  the  yet  strong  bladder-muscles. 
Hence  it  would  seem  to  follow  that  the  greatest  danger  of  kidney  in- 
fection from  the  bladder  exists  in  the  early  stages  of  cystitis ;  later, 
when  the  submucous  and  muscular  coats  are  infiltrated  and  the 
vesical  contractions  are  feeble,  intravesical  tension  is  not  sufficiently 
high  to  overcome  that  exerted  by  the  stream  of  urine  descending  from 
the  kidney.  Tubercular  cystitis,  according  to  Lipowski,  forms  an  ex- 
ception to  this  rule. 

Treatment  of  Cystitis. — From  what  has  been  said  concerning  the 
cause  of  cystitis,  it  is  plain  that  the  prevention  of  this  disease  depends 
upon  the  avoidance  of  local  congestion  and  of  the  entrance  of  germs 
into  the  bladder. 

Local  congestion  is  avoided  by  attention  to  the  rules  of  hygiene. 
Rest  in  bed  is  not  desirable.  Indeed,  in  cases  of  partial  urinary 
retention  it  seems  to  favor  rather  than  lessen  pehac  congestion. 
Regular  daily  exercise  in  the  open  air,  such  as  driving,  walking,  or 
riding  the  horse  or  bicycle,  in  accordance  with  the  strength  of  the 
patient,  is  to  be  commended.  The  diet  must  be  so  regulated  that 
digestion  is  perfectly  performed ;  even  slight  gastric  or  intestinal  dis- 
orders render  the  urine  distinctly  irritating. 

Usually  diluent  drinks  are  serviceable,  particularly  at  night,  since 
the  urine  is  most  strongly  acid  during  the  small  hours.  Natural 
mineral  waters  may  be  ordered  in  accordance  with  the  dyscrasia  of 
the  patient.  Thus,  hthia  water  would  be  indicated  in  the  gouty  or 
rheumatic,  ferruginous  waters  in  the  anaemic  or  in  those  subject  to 
looseness  of  the  bowels. 

Careful  attention  should  be  given  to  the  condition  of  the  skin. 
The  patient  should  bathe  daily  in  either  hot  or  cold  water,  according 
to  preference.  This  bath  should  be  followed  by  vigorous  friction. 
The  sweating-box  described  under  the  treatment  of  syphilis  is  par- 
ticularly serviceable,  and  may  be  used  daily  when  there  is  no  idio- 
syncrasy and  when  it  does  not  produce  weakness  or  debility.  The 
feelings  of  the  patient  will  be  the  best  guide  in  deciding  on  this  course 
of  treatment.  The  sweat  should  be  followed  by  a  cool  sponging  and 
vigorous  friction. 

Regular  evacuation  of  the  bowels  is  a  matter  of  cardinal  impor- 
tance. It  has  been  shown  experimentally  that  rectal  obstruction  is 
almost  immediately  followed  by  the  appearance  of  enormous  numbers 
of  colon  baciin  in  the  urine,  coming  either  through  the  kidneys  or 
conceivably  directly  from  the  rectum  to  the  bladder  through  ttie  thin 
intervening  walls.  A  daily  bowel  movement  is  best  procured  by  ex- 
ercise and  diet.     If  these  means  are  not  efficient,  mild  sahnes,  such- 


CYSTITIS.  421 

as  Hunyadi  water,  may  be  administered  in  the  early  morning,  or  rectal 
enemata  of  normal  saline  solution  may  be  given. 

An  examination  of  the  urine  should  be  made  to  determine  the 
presence  of  excess  of  uric  acid,  oxalates,  or  other  ingredients  which 
are  irritating  to  the  vesical  mucosa  and  which  can  be  lessened  by 
appropriate  diet  and  medication.  Chilling  of  the  surface,  wet  feet, 
prolonged  standing,  elaborate  meals,  highly  seasoned  foods,  pastry, 
sweets,  alcohol,  and  rhubarb  are  to  be  avoided. 

When  there  are  local  causes  for  reflex  irritability,  as  hemorrhoids, 
varicocele,  tight  prepuce,  or  narrow  meatus,  these  should  receive  ap- 
propriate surgical  treatment.  Urethral  causes  of  bladder-irritabihty 
or  of  partial  retention  of  urine,  such  as  stricture  of  either  large  or 
small  calibre,  should  be  relieved  as  promptly  as  possible. 

As  a  means  of  preventing  direct  infection  when  this  is  threatened 
because  of  inflammation  of  the  urethra  or  of  the  prostate,  or  because 
of  proposed  surgical  interference,  it  is  well  to  render  the  urine  not 
•only  bland  but  even  mildly  antiseptic.  This  end  may  be  accom- 
plished by  the  administration  of  salol,  urotropin,  or  boric  acid,  as 
already  described  (five  grains  of  salol,  five  to  ten  grains  of  boric  acid, 
or  five  grains  of  urotropin  four  times  a  day). 

Acute  cystitis,  or  violent  congestion  typified  by  caniharidal  poison- 
ing, is  treated  by  hot  baths,  rest  in  bed,  elevation  of  the  pelvis,  and 
thorough  evacuation  of  the  lower  bowel,  best  procured  by  salines  and 
cold  enemata  of  salt  water. 

For  the  relief  of  the  frequent  painful  urination  belladonna  and 
opium  suppositories  are  indicated.  These  should  be  repeated  hourly 
till  they  accomplish  the  purpose  for  which  they  are  given  (extract 
of  opium,  one-half  grain ;  extract  of  belladonna,  one-fourth  grain). 
Rectal  applications  through  a  catheter  by  means  of  a  piston  syringe, 
of  fifteen  to  thirty  grains  of  antipyrin  and  ten  to  twenty  drops  of  laud- 
anum dissolved  in  one-half  ounce  of  water,  are  more  useful  and  less 
disadvantageous  than  morphine  or  opium  suppositories.  Hot  com- 
presses should  be  applied  to  the  entire  abdomen,  and  should  be 
changed  frequently.  Diluents  and  sedatives  should  be  given  by  the 
mouth.  In  severe  cases  leeches  to  the  perineum  and  the  hypogastric 
region  are  extremely  serviceable.  If  there  is  fever  with  consequent 
strongly  acid  urine,  to  the  copious  draughts  of  water  should  be 
added  potassium  citrate  or  acetate,  in  doses  of  ten  grains  six  times 
daily,  or  spirit  of  nitrous  ether  in  drachm  doses  hourly,  or  liquor 
potassii  citratis  may  be  administered  in  tablespoonful  doses  well 
diluted  every  one  or  two  hours.  Salol  and  boric  acid  should  always 
be  given  for  the  purpose  of  rendering  the  urine  slightly  antiseptic. 


422  GEN ITO-URINAEY   DISEASES   AND   SYPHILIS. 

iWheri- the  symptoms  are  unusually  severe,  patients  often  assume  the 
knee-elbow  position,  since  thus  the  pressure  of  the  abdominal  viscera 
is  taken  from  the  bladder  and  venous  engorgement  is  lessened.  This 
position  is  serviceable,  and  should  be  advised  w^hen  it  is  not  spon- 
taneously assumed.  When  large  doses  of  opium  fail  to  relieve  pain 
and  spasm,  the  ice-bag  introduced  into  the  rectum  may  be  of  use. 
V  When  the  symptoms  are  purely  the  result  of  congestion — i.e., 
w^hen  there  is  no  vesical  infection — all  intravesical  manipulations 
should  be .  avoided,  unless  retention  threatens,  though  it  has  been 
shown  that  pain  may  be  reheved  promptly  and  for  several  hours  by 
the  instillation  of  fifteen  drops  of  a  one  per  cent,  solution  of  cocaine. 
In  certain  cases  of  gonorrhoeal  prostato-cystitis  where  the  inflamma- 
tion is  Hmited  to  the  prostatic  urethra  and  the  portion  of  the  trigonum 
nearest  the  vesical  orifice,  an  instillation  of  ten  drops  of  a  five  per  cent, 
solution  of  silver  nitrate  will  give  almost  immediate  relief. 

The  bleeding  of  acute  inflammation  is  usually  slight,  and  is  often 
of  advantage,  since  it  lessens  congestion  ;  it  requires  no  special  treat- 
ment. 

Should  retention  supervene,  if  it  is  entirely  due  to  spasm  and 
congestion,  an  attempt  should  be  made  to  relieve  it  by  a  hot  general 
bath,  the  patient  being  directed  to  micturate  while  still  in  the  tub. 
Hot  compresses  or  turpentine  stupes  to  the  abdomen  and  full  doses 
of  opium  and  hyoscyamus  or  belladonna  are  also  indicated.  When 
retention  is  complete  and  distention  pronounced,  there  should  be  no 
hesitation  in  employing  the  catheter,  ether  being  given  if  this  manipu- 
lation is  excessively  painful. 

In  the  course  of  a  week  to  ten  days  the  acute  inflammation  will 
subside,  and,  provided  there  are  no  local  conditions  which  tend  in- 
definitely to  prolong  congestion,  convalescence  may  be  complete. 
Usually  the  disease  becomes  chronic,  and  may  thus  continue  for 
years,  giving  rise  to  no  symptoms  other  than  a  small  quantity  of  pus 
in  the  urine,  but  being  subject  to  acute  exacerbations. 

Treatment  of  chronic  cystitis  will  not  be  successful  unless  the  pre- 
disposing causes,  such  as  urethral  obstruction,  stone,  and  tumor,  are 
removed.  The  diet  should  be  so  regulated  that  the  food  is  thor- 
oughly digested  and  the  gastro-intestinal  tract  kept  free  from  irrita- 
tion ;  highly  seasoned  articles,  desserts,  and  alcohols  are  in  general 
to  be  avoided.  The  natural  mineral  waters  are  useful  as  diluents, 
and  maybe  taken  between  meals.  Saline  diuretics— and  among  these 
^potassium  citrate  is  the  most  valuable — should  be  given,  well  diluted, 
■in  quantities  sufficient  to  keep  the  urine  nearly  neutral  in  reaction. 
In  the  absence    of  a   rheumatic   diathesis,   and   particularly  where 


CYSTITIS.  '423 

.there  is  an  associated  anaemia,  the  ferruginous  mineral  waters  are 
of  use. 

Of  the  long  list  of  drugs  used  by  the  mouth  comparatively  few 
have  any  real  value,  Urotropin  and  benzoic  acid  often  do  good 
when  the  urine  is  markedly  alkaline.  They  may  be  given  in  five- 
to  ten-grain  doses  six  times  a  day.  The  dose  is  regulated  by  the 
effect  upon  the  urine.  Acid  sodium  phosphate  in  half-drachm  doses 
every  three  hours  is  a  useful  drug  for  acidifying  the  urine  and  relaxing 
the  bowels.  The  balsams  are  extremely  useful  in  both  subacute  and 
chronic  cystitis.  Of  these  sandal  wood  oil  is  one  of  the  best,  given 
in  the  form  of  a  capsule  combined  with  oil  of  cinnamon. 

R      01.  santali,  "Ix  ; 

01.  cinnamomi,  Tr\^ii. 
Ft.  capsula  i. 
Sig. — Take  three  such  capsules  daily,  one  hour  after  each  meal,  gradually 
increasing  the  number. 

To  be  effective,  the  sandal  wood  oil  must  be  given  in  full  doses. 
This  is  often  impossible,  because  of  the  gastric  derangement  it  occa- 
sions. 

Salol  and  boric  acid  are  valuable  from  their  germicidal  qualities. 
They  both  tend  to  correct  digestive  disturbances  rather  than  to  pro- 
duce them. 

Of  the  many  other  drugs  which  have  been  recommended  and 
which  are  commonly  employed,  perhaps  the  most  useful  are  pichi 
extract  five  grains  every  two  hours  in  capsules ;  cantharides  in  drop 
doses  every  one  or  two  hours  as  a  stimulant  in  extremely  chronic 
cases  ;  turpentine  five  to  fifteen  drops  in  emulsion  every  three  hours ; 
oil  of  eucalyptus  five  to  ten  drops  in  emulsion  every  two  hours  ;  fluid 
extract  of  buchu  or  uva  ursi  in  drachm  doses  every  two  or  three 
hours ;  arbutin  in  doses  of  three  to  five  grains  three  to  six  times 
daily. 

Generally,  if  predisposing  causes  are  removed,  the  bladder  put 
at  rest,  and  the  urine  rendered  unirritating,  stimulant,  and  slightly 
antiseptic,  so  that  ammoniacal  fermentation  does  not  take  place,  the 
symptoms  rapidly  improve,  and  the  patient  recovers.  If,  however, 
these  milder  hygienic  and  medicinal  methods  fail  and  free  vesical 
suppuration  continues,  local  treatment  is  indicated.  This  may  be 
applied  either  by  instillation  or  by  irrigation. 

The  method  of  employing  instillation  has  been  described  already 
under  the  treatment  of  posterior  urethritis.  Irrigations  are  practised 
with  a  fountain  syringe  fitted  to  either  a  short  urethral  nozzle  or  a 


424  genito-ukij^ary  diseases  and  syphilis. 

soft  rubber  catheter  of  comparatively  full  size.  Irrigations  with  a 
short  urethral  nozzle  may  be  employed  when  the  vesical  tonicity  is 
good  and  the  bladder  has  the  power  of  completely  and  painlessly 
evacuating  its  contents.  In  chronic  cystitis  this  condition  is  ex- 
tremely rare:  hence  the  method  of  choice  is  usually  that  with  the 
catheter. 

Instillations  are  indicated  when  inflammation  is  particularly  se- 
vere at  or  about  the  neck  of  the  bladder.  This  is  usually  shown  by 
the  symptoms,  strangury  being  always  most  pronounced  when  in- 
flammation is  thus  located.  These  instillations  act  directly  upon  the 
prostatic  urethra  and  the  neck  of  the  bladder.  They  may  at  first 
seem  to  aggravate  tenesmus  and  pain,  but  this  is  shortly  followed  by 
marked  relief.  The  solutions  of  choice  are  those  of  silver  nitrate 
with  a  maximum  strength  of  five  per  cent.  It  is  well  to  begin  with 
a  one-half  per  cent,  solution  and  gradually  increase  the  strength  till 
the  symptoms  are  relieved. 

Minet  advises  instillations  two  or  three  times  a  week  of  two  to 
four  cubic  centimetres  of  two  per  cent,  aqueous  solution  of  pyrogallic 
acid  to  relieve  painful  frequency  of  micturition. 

Instillations  are  repeated  every  second,  third,  or  fourth  day,  in 
accordance  with  the  reaction  they  excite.  The  immediate  pain  they 
cause  may  be  lessened  by  preceding  them  by  an  application  of 
cocaine.  When  it  is  desired  to  affect  a  larger  surface  of  the  bladder, 
two  to  four  drachms  may  be  employed.  The  strength  of  the  silver 
solution  when  it  is  thus  used  should  not  be  more  than  one  per  cent. 
When  the  treatment  is  inaugurated  it  is  well  to  begin  with  half  a 
grain  to  the  ounce.  Silver  nitrate  instillations  are  particularly  ser- 
viceable in  gonorrhceal  cystitis,  and  in  those  chronic,  non-tubercular 
forms  of  inflammation  which  are  not  dependent  upon  urethral  ob- 
struction and  retention. 

Sublimate  instillations  are  useful  in  tubercular  cystitis.  They 
also  render  good  service  in  the  inflammation  due  to  gonococci,  colon 
bacilli,  and  ordinary  pyogenic  microbes.  This  method  of  treatment 
was  first  popularized  by  Guyon,  who  reported  extraordinarily  suc- 
cessful results.  The  quantity  injected  into  the  bladder  should  be 
from  one  to  two  drachms,  and  that  into  the  posterior  urethra  from 
five  to  fifteen  drops.  Weak  solutions  are  first  employed  (1  to  4000), 
and  the  strength  is  gradually  increased  (1  to  500).  These  instillations 
may  be  repeated  every  second  or  third  day,  and  should  be  preceded 
by  irrigations  unless  the  bladder  is  extremely  irritable. 

Irrijalions  are  given  with  strict  attention  to  cleanliness.  The  quan- 
tity injected  varies  in  accordance  with  the  capacity  and  irritability  of 


CYSTITIS.  425 

the  bladder.  It  is  a  good  rule  not  to  inject  a  sufficient  bulk  of  fluid  to 
cause  pain  from  tension. 

The  most  efficient  irrigation  is  that  of  the  silver  salts.  The  solu- 
tion employed  varies  in  strength  from  1  to  10,000  to  1  to  500,  In 
extremely  chronic  cases  much  stronger  solutions  than  these  are  not 
only  tolerated  but  are  beneficial.  The  urine  is  first  passed.  The 
bladder  is  then  irrigated  with  boiled  v^ater  until  this  comes  away  clear ; 
finally  one  or  two  ounces  of  the  silver  solution  are  thrown  in  and 
allowed  to  escape  almost  immediately.  Strong  silver  irrigations  are 
repeated  daily  or  every  second  or  third  day,  in  accordance  with  the 
violence  of  reaction.  When  they  excite  severe  pain  and  apparently 
aggravate  symptoms, — and  this  is  particularly  likely  to  occur  in  tuber- 
cular cystitis, — other  antiseptics  should  be  employed.  After  silver 
nitrate  the  most  efficient  lotions  are  those  of  potassium  permanganate 
1  to  6000  to  1  to  500,  boric  acid  five  to  fifteen  grains  to  the  ounce, 
salicylic  acid  1  to  1000  (made  from  an  alcoholic  solution  containing 
eight  grains  to  the  ounce),  and  ichthyol  one-half  to  two  per  cent. 
When  even  the  weakest  of  these  antiseptics  occasions  pain  and  marked 
reaction,  and  when  it  is  certain  that  these  sequelae  are  not  due  to 
bladder-tension  incident  to  the  injection  of  too  great  a  quantity  at  one 
time,  recently  boiled  seven-tenths  per  cent,  sodium  chloride  solution 
may  be  employed. 

It  should  be  clearly  understood  that  in  cases  of  chronic  cystitis 
the  bladder  mucosa  is  infected  not  only  upon  its  surface  but  also  in 
its  depth,  and  that  no  antiseptic  can  reach  germs  which  are  embedded 
in  the  tissues.  The  function  of  lavage  is  not  to  render  the  bladder- 
wall  sterile,  but  rather  to  remove  decomposing  pus  and  urine,  to 
inhibit  or  destroy  those  germs  which  lie  upon  the  surface,  to  stimulate 
healthfully  the  chronically  engorged  vesical  walls,  and  to  leave  in  the 
bladder  a  residuum  which  will  prevent  further  fermentation  of  the 
urine,  with  its  irritating  effect  upon  the  mucosa.  It  is  therefore  well, 
after  having  practised  irrigation,  to  leave  from  half  a  drachm  to  an 
ounce  of  antiseptic  solution  in  the  bladder.  This  is  particularly  indi- 
cated when  evacuation  of  the  last  few  drachms  of  urine  is  painful. 

No  rule  can  be  given  as  to  the  number  of  irrigations  which  are 
indicated.  Where  there  is  profuse  suppuration  with  rapid  decompo- 
sition, ammonuria,  and  retention,  the  bladder  should  be  washed  out 
at  least  twice  daily,  and  often  this  process  can  be  advantageously  re- 
peated three  or  four  times.  Where  the  cystitis  is  slight  in  grade  and 
the  urine  is  not  decomposed,  irrigations  may  be  practised  every  two  or 
three  days.     Daily  irrigation  at  least  is  generally  required. 

When  in  spite  of  instillations  and  irrigations,  or  because  of  pain, 


426  GENITO-ITRINAEY   DISEASES   Al^J)   SYPHILIS. 

spasm,  and  undue  reaction,  these  methods  of  treatment  are  not 
practicable,  the  cystitis  hecoming-  steadily  worse,  and  constitutional 
symptoms  developing,  permanent  catheterization  is  indicated.  The 
technique  of  this  method  is  fully  described  under  the  treatment  of 
retention  from  prostatic  obstruction:  If  the  catheter  is  properly 
held  in  place,  the  bladder  is  constantly  drained  and  thus  put  at  r6st. 
Through  this  catheter  are  practised  irrigations  with  the  solution  which 
excites  least  inflammatory  reaction. 

If  these  methods  of  treatment  do  not  relieve  the  patient  and  it  is 
evident  that  his  strength  is  rapidly  failing  from  septic  absorption, 
suprapubic  or  perineal  drainage  is  indicated.  Unless  there  is  some 
distinct  reason  for  choosing  the  suprapubic  route,  as,  for  instance,  the 
necessity  for  operating  on  a  vesical  tumor  or  for  treating  a  tubercular 
ulcer,  the  perineal  incision  should  be  the  one  of  choice,  except  in  cases 
of  vesical  and  prostatic  tuberculosis. 

When  the  cutting  operation  is  forced  on  the  surgeon  in  place  of 
catheterization  and  irrigations,  because  of  the  pain  and  reaction  which 
■they  excite,  forcible  dilatation  of  the  prostatic  urethra  is  a  most  im- 
portant procedure,  since  this  will  always  for  a  time  and  often  per- 
manently relieve  the  violent  and  exhausting  tenesmus  from  which  this 
class  of  patients  habitually  suffer.  The  bladder  is  entered  through 
the  membranous  urethra.  The  drainage-tube  should  be  of  large 
calibre,  about  the  size  of  the  little  finger,  and  its  walls  should  be 
sufficiently  rigid  to  prevent  flattening  from  pressure  of  the  tissues. 
The  incision  is  packed  with  iodoform  gauze,  and  the  perineal  drain 
is  attached  to  a  rubber  tube  which  passes  beneath  the  surface  of  an 
antiseptic  lotion  held  in  a  suitable  receptacle.  The  latter  should  be 
so  arranged  that  it  is  always  beneath  the  level  of  the  bladder.  This 
perineal  tube  secures  continuous  drainage  and  absolute  rest,  and 
enables  the  surgeon  to  employ  irrigations  to  the  best  effect. 

PERIVESICAL   INFLAMMATION. 

Two  forms  of  perivesical  inflammation  are  described  by  Halle,  the 
cicatricial  and  the  suppurative. 

Cicatricial  pericystitis  is  the  result  of  chronic  pelvic  cellulitis,  and 
is  characterized  by  accumulations  of  sclero-adipose  tissue  about  the 
base  and  sides  of  the  bladder.  The  perivesical  tissue  becomes  dense 
and  greatly  thickened,  and  firmly  mats  the  pelvic  organs  together. 
The  masses  of  this  tissue,  by  forming  about  the  vesical  insertion  of 
the  ureters,  may  produce  occlusion  of  these  canals. 

Suppurative  pericystitis  appears  in  the  form  of  abscesses,  develop- 
ing in  the  normal  fibro-adipose  tissue  surrounding  the  bladder.    Usu- 


CYSTITIS.  427, 

ally  these  abscesses  are  secondary  to  prostatitis  or  cystitis.  It  is 
evident  that  they  may  form  in  case  of  wound  or  ulceration  of  the 
bladder.  The  ulceration  may  be  tubercular  or  malignant.  More 
commonly  it  is  erosive,  and  is  caused  by  stone  or  foreign  body.  The 
abscesses  of  parenchymatous  cystitis  may  rupture  externally  and 
affect  the  perivesical  tissues  ;  usually  they  discharge  into  the  bladder. 
Suppurative  pericystitis  due  to  stone  ulcerating  through  the  bladder- 
M^all  is  localized  and  develops  slow^ly.  It  may  discharge  upon  the 
skin  surface,  usually  in  the  perineum,  or  empty  into  the  rectum  or 
the  peritoneal  cavity. 

Prevesical  Abscess. — There  is  one  form  of  perivesical  inflamma- 
tion w^hich,  from  the'  fact  that  it  is  often  primary  and  if  promptly 
recognized  can  be  successfully  treated,  requires  special  consideration  ; 
this  is  prevesical  suppuration,  or  abscess  in  the  space  of  Retzius. 

This  space  is  entirely  external  to  the  peritoneum,  and  serves  in 
part  to  give  the  bladder  room  to  expand  and  fill  with  urine.  It  is 
bounded  anteriorly  by  the  pubis  and  the  anterior  layer  of  the  trans- 
versalis  fascia  of  Cooper,  behind  by  the  posterior  layer  of  that  fascia 
anc\  by  the  bladder.  That  part  of  the  space  which  extends  upward 
beyond  the  pubis  is  limited  above  by  the  line  of  union  of  the  two 
layers  of  fascia  which  are  given  off  at  the  lower  border  of  the  sheath 
of  the  recti  muscles  posteriorly,  and  has  for  its  lateral  limits  the  union 
of  these  layers  with  the  aponeurosis  of  the  transversalis  and  oblique 
muscles.  Below,  the  space  is  limited  by  the  prostatic  sheath  and  the 
superior  aponeurosis  of  the  true  pelvis. 

Suppuration  in  this  region  may  be  caused  by  traumatism,  oper- 
ative or  otherwise,  or  by  infection  of  neighboring  organs,  such  as  the 
bladder,  prostate,  uterus,  etc.  Englisch,  quoted  by  Thorndike,  classes 
all  cases  of  prevesical  suppuration  under  three  headings:  (1)  those 
caused  by  traumatism  ;  (2)  those  caused  by  metastasis  ;  and  (3)  those 
caused  by  direct  extension  from  neighboring  organs  or  tissues.  • 

It  is  evident' from  the  boundaries  of  this  space  that  pus  may  open 
through  the  anterior  abdominal  wall,  into  the  rectum,  the  bladder  or 
urethra,  the  perineum,  or  the  peritoneal  cavity.  A  certain  proportion 
of  these  cases  give  a  tubercular  history,  but  proof  as  to  the  causative 
agency  of  the  tubercle  bacillus  is  wanting.  •  *        ■, 

Symptoms. — The  symptoms  of  prevesical  suppuration  are  vesical 
tenesmus  and  irritability,  pain,  not  sharply  localized,  often  referred 
to  the  bowels  and  associated  with  digestive  disturbances,  the  forma- 
tion of  a  tumor  occupying  the  position  of  a  distended  bladder  and 
discoverable  on  suprapubic  or  bimanual  palpation,  local  tenderness, 
and  usually  constitutional  symptoms  of  suppuration.  n 


428  GENITO-rPvINAEY  DISEASES  AND  SYPHILIS. 

Diagnosis. — The  formation  of  inflammatory  infiltration  behind  the 
pubis  associated  with  symptoms  of  vesical  irritability  would  in  the 
absence  of  cystitis  be  sufficiently  characteristic  of  prevesical  inflam- 
mation. When  cystitis  is  present  the  persistence  of  the  tumor  after 
thorough  evacuation  of  the  bladder-contents  would  also  be  pathogno- 
monic. When  the  abscess  points  forward  in  the  middle  line,  perhaps 
the  only  condition  with  which  it  is  likely  to  be  confused  is  post-rectus 
suppuration,  the  pus  then  lying  behind  the  rectus  muscle  and  be- 
tween it  and  the  layer  of  fascia  which  descends  directly  to  the  pubis. 
In  this  case  the  pus  would  be  limited  laterally  by  the  borders  of  the 
recti  muscles  and  would  extend  upward.  The  induration  of  prevesi- 
cal inflammation  extends  laterally  beyond  the  limits  of  the  recti  mus- 
cles, and  is  usually  symmetrically  developed  in  the  two  sides.  Ex- 
ceptionally the  abscess  extends  towards  one  side  only.  We  have 
operated  on  one  such  case  where  because  of  associated  intestinal 
symptoms  the  condition  was  diagnosed  as  incarcerated  hernia.  Care- 
ful bimanual  palpation  suggested  the  true  nature  of  the  affection,  and 
the  presence  of  pus  was  confirmed  by  an  incision. 

Prognosis. — This  is  favorable,  especially  when  the  condition  is 
properly  diagnosed  and  treated  by  early  evacuation  of  the  pus.  Of 
Englisch's  thirty-three  reported  cases  four  died  from  a  general  purulent 
peritonitis  following  perforation  of  the  abscess  into  the  peritoneal 
cavity. 

Treatment. — Suppuration  requires  evacuation  and  drainage.  In 
the  absence  of  pointing,  incision  should  be  made  in  the  middle  line 
directly  over  the  pubis.  Drainage  should  be  secured  by  gauze  pack- 
ing. The  same  rule  applies  to  all  perivesical  suppuration.  The  pus 
should  be  evacuated  as  soon  as  it  is  detected. 

In  the  treatment  of  that  form  of  chronic  perivesical  inflammation 
which  is  characterized  by  the  formation  of  masses  of  fibro-lipomatous 
tissue  attention  should  first  be  directed  to  the  cure  of  the  condition 
which  has  produced  or  is  keeping  up  pelvic  cellulitis.  This  may  be 
an  untreated  cystitis,  with  diverticula,  or,  in  the  case  of  women,  endo- 
metritis and  perimetritis.  Hot  rectal  douches  of  normal  saline  solu- 
tion and  massage  through  the  rectum  and  over  the  pubis  may  be 
serviceable, 

TUBERCULOSIS  OF  THE   BLADDER. 

Tuberculosis  of  the   bladder  is  a  disease  of   early  and   middle 

life,  occurring  chiefly  between  the  ages  of  fifteen  and  forty  ;  it  has 

been  observed,  however,  in  children  four  or  five  years  old,  and  Tapret 

noted  a  case  occurring  in  a  man  at  the  extreme  age  of  ninety-seven. 


VESICAL  TUBEECULOSIS.  429 

It  is  found  more  frequently  in  males  than  in  females,  and  is  usu- 
ally associated  with  tuberculosis  of  the  seminal  vesicles  and  of  the 
prostate. 

Etiology. — The  predisposing  causes  have  been  found  to  be  tubercu- 
lous nephritis,  a  general  tubercular  tendency,  often  inherited,  together 
with  an  infectious  cystitis,  generally  gonorrhoeal  in  origin. 

The  exciting  cause  is  infection  with  the  tubercle  bacilli.  This  in- 
fection may  be  primary  or  secondary.  The  secondary  infection  is 
nearly  always  descending.  Herberg,  from  the  records  of  several 
thousand  autopsies,  finds  that  genito-urinary  tuberculosis  is  secondary 
in  two-thirds  of  all  cases,  and  that  when  it  is  primary  it  generally 
affects  the  sexual  organs.  Primary  tuberculosis  of  the  urinary  organs 
is  most  likely  to  attack  the  kidneys.  Secondary  infection  exception- 
ally takes  place  directly  from  the  prostatic  urethra,  Krzywicki  stating 
that  this  gland  is  affected  in  ninety-three  per  cent,  of  cases  of  genito- 
urinary tuberculosis,  usually  through  the  ureter  from  renal  tubercu- 
losis. Fournier  holds  that  direct  inoculation  is  possible  during  coitus 
by  tubercular  mucus  from  the  vagina  entering  the  male  urethra  and 
infecting  the  bladder.  An  ascending  infection  from  the  epididymis 
and  vas  undoubtedly  occurs. 

It  is  impossible  to  say  with  certainty  that  a  given  case  of  vesical 
tuberculosis  is  primary ;  we  must  almost  always  remain  in  doubt  as 
to  the  presence  or  absence  of  the  disease  in  the  kidneys.  Frequently 
its  existence  there  may  be  demonstrated,  but  it  may  be  present,  and 
to  a  formidable  extent,  without  a  single  diagnostic  symptom  having 
shown  itself.  When  both  bladder  and  kidneys  are  involved,  it  is 
impossible  to  determine,  even  by  post-mortem  examination,  in  which 
organ  the  disease  was  primary.  Nor  do  the  symptoms  throw  light  on 
the  matter,  since  in  the  earliest  stages  of  surgical  tuberculosis,  when  it 
appears  to  be  primary  in  the  bladder,  an  examination  may  show 
nodulations  of  the  prostate  and  seminal  vesicles,  or  renal  hasmaturia 
may  prove  that  the  kidneys  are  already  involved,  although  no  symp- 
toms indicating  the  implication  of  these  organs  have  manifested 
themselves. 

Halle  says,  "  The  absolute  absence  of  symptoms  in  the  tubercular 
lesions  of  the  kidney  and  ureter  cannot  be  too  strongly  emphasized. 
Often  the  only  indications  are  failure  of  the  general  health  and  an 
indolent  bacillary  pyuria,  and  even  this  may  be  lacking  if  the  ureter 
has  become  speedily  obliterated.  These  diseases,  therefore,  at  their 
beginning,  and  even  up  to  an  advanced  stage,  are  frequently  not 
recognized.  It  is  only  when  the  bladder  becomes  affected  and  the 
pains  of  cystitis  or  cystalgia  manifest  themselves  that  medical  advice 


430  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

is  sought.  Often  even  then  the  attention  of  the  physician  is  entirely- 
directed  to  the  dominating  painful  vesical  symptoms,  and  he  is  apt  to 
attribute  to  the  bladder  alone  phenomena  which  arise  from  renal 
lesions.  Bearing  these  facts  in  mind,  it  will  be  found  that  in  many 
patients  the  urinary  tuberculosis,  considered  as  primarily  vesical  or 
prostatic,  and  classed  among  the  ascending  tuberculoses,  has  in 
reality  begun  insidiously  in  the  kidney.  Autopsies  support  this  view. 
In  many  cases  of  wide-spread  tuberculosis  of  the  urinary  tract  it  is 
possible  to  demonstrate  the  greater  age  of  the  renal  lesions."  Halle 
concludes,  "  In  a  word,  I  am  of  the  opinion  that  urinary  tuberculosis 
begins  in  the  kidney  oftener  than  clinical  observation  would  lead  us 
to  suspect,  and  that  it  is  especially  a  manifestation  of  general  tuber- 
cular infection  localizing  itself  in  the  kidney,  which  it  reaches  by  way 
of  the  circulation."  It  must  be  remembered  that  even  though  the 
kidneys  are  tubercular  and  constantly  discharge  tubercle  bacilH  the 
bladder  may  remain  entirely  healthy. 

Exceptionally,  by  the  method  of  exclusion  we  can  arrive  at  a  diag- 
nosis of  primary,  hence  haematogenic,  cystitis.  The  observations  of 
Weigert,  Heller,  Weichselbaum,  and  others  have  shown  that  the  blood 
is  one  of  the  principal  channels  by  which  tuberculosis  is  propagated 
throughout  the  system.  Pathological  anatomy  tends  to  confirm  this 
theory.  The  initial  changes  are  found  to  be  grayish  miliary  tubercles 
situated  on  the  superficial  layer  of  the  epithelium.  Ulceration  is 
always  a  later  stage.  Clado,  having  previously  wounded  the  vesical 
mucosa  of  a  rabbit,  gave  it  a  subcutaneous  injection  of  tubercle  bacilli. 
It  developed  vesical  tuberculosis. 

Among  thirty-five  cases  observed  by  Casper,  in  three  the  bladder 
was  found  to  be  the  sole  seat  of  the  disease.  In  fourteen  cases  the 
kidneys  were  also  the  seat  of  tuberculosis  ;  in  seven  cases  the  genital 
organs ;  in  two  cases  the  joints ;  in  five  cases  the  lungs  ;  in  three 
cases  general  tuberculosis  existed.  In  one  case  the  patient  was  the 
subject  of  lupus. 

According  to  Koch,  the  following  modes  of  infection  are  pos- 
sible : 

(a)  In  the  presence  of  tubercle  bacilli  in  the  body:  (1)  Infection 
through  the  blood  current ;  (2)  infection  by  way  of  the  lymph-chan- 
nels; (3)  infection  by  the  excretion  of  tubercle  bacilli  through  the 
kidneys  with  or  without  disease  of  these  organs. 

(6)  Through  the  introduction  of  bacilli  from  without:  (1)  By  cohabi- 
tation ;  (2)  by  catheterism. 

Pathological  Anatomy. — In  well-marked  cases  of  tubercular  in- 
flammation of  the  bladder  there  is  a  pericystitis,  characterized  by  yel- 


VESICAL   TUBEKCULOSIS.  431 

low,  fibro-lipomatous  infiltration  and  degeneration  ;  the  bladder- walls 
are  thickened  and  rugous.  The  mucous  membrane  is  ecchymotic  in 
spots.  Granulations  can  rarely  be  seen,  but  when  visible  they  appear 
as  fine  gray  dots,  sometimes  confluent,  but  never  in  such  masses 
as  are  seen  in  the  kidney.  Ulcerations,  either  single  or  multiple, 
are  found  in  the  mucous  membrane.  Their  edges  are  irregularly 
excavated,  their  base  a  greenish  gray  covered  with  thick  pus.  In 
depth  they  are  very  variable,  sometimes  only  invading  the  mucous 
membrane,  and  again  they  may  even  perforate  the  bladder-walls  and 
produce  perivesical  abscesses,  or  fistulse  opening  into  the  rectum, 
vagina,  or  hypogastrium  ;  fistulae,  however,  are  rare.  Microscopi- 
cally, it  is  seen  that  the  tubercular  granulations  arise  in  the  super- 
ficial layers  of  the  mucous  membrane,  and  in  these  lesions,  which  are; 
commonly  in  or  near  the  trigonum,  the  tubercle  bacillus  and  many 
septic  bacteria  will  be  found. 

Symptoms. — Vesical  tuberculosis  may  develop  so  insidiously  that 
its  presence  is  not  suspected  till  a  urinary  examination,  made  in  the 
course  of  an  examination  for  life  insurance,  for  instance,  shows  the 
pus  or  blood.  In  these  cases  th§re  have  been  no  symptoms,  or 
perhaps,  when  questioned,  the  patient  will  remember  that  he  has 
been  slightly  troubled  by  a  somewhat  frequent  urination,  chiefly  after 
meals  and  during  the  night.  The  urine  is  clear  and  limpid,  is  passed 
every  hour  or  so,  and  the  frequency,  which  in  children  may  cause 
nocturnal  incontinence,  is  aggravated  by  the  dorsal  decubitus. 

Hsematuria  in  many  cases  is  an  early  symptom..  The  bleeding  is 
slight,  spontaneous,  and  sometimes  terminal,  a  few  drops  of  pure  blood 
following  the  claret-colored  urine.  It  often  stops  as  suddenly  and 
inexplicably  as  it  begins,  and  may  not  reappear  for  days  or  weeks. 
This  symptom  becomes  gradually  less  prominent  as  the  disease  pro- 
gresses. Exceptionally  there  may  be  a  profuse  hemorrhage,  but 
where  this  occurs  the  presence  of  vesical  tumor  should  be  suspected. 

Pain,  when  pronounced,  usuafly  denotes  the  onset  of  cystitis,  to 
which  the  tubercular  bladder  is  almost  inevitably  doomed.  The 
usual  cause  of  cystitis  is  catheterization,  but  it  develops  spontaneously 
in  the  absence  of  instrumentation.  Cystitis  having  been  inaugurated, 
pain  becomes  one  of  the  most  constant,  prominent,  and  harassing 
symptoms  of  the  disease.  The  patient  is  tortured  day  and  night  by 
urgent  desire  to  urinate  and  by  violent  tenesmus,  sometimes  recurring 
every  few  minutes,  and  the  pain  may  be  felt  at  all  stages  of  urination. 
These  symptoms  are  most  pronounced  when  the  tubercular  process 
attacks  the  region  of  the  trigonum ;  when  the  lesions  involve  other 
parts  of  the  bladder  it  may  happen  that  an  advanced  stage  of  vesi- 


432  GENITO-UEINAEY  DISEASEb   AND  SYPHILIS. 

cal  tuberculosis  will  be  reached  before  the  slightest  symptom  of  pain 
manifests  itself. 

Retention  of  urine  occasionally  results  from  spasm  and  inflamma- 
tory obstruction  of  the  internal  urethral  orifice,  and  again  true  incon- 
tinence may  arise  from  destruction  of  the  neck  of  the  bladder  by  the 
tubercular  process. 

Pus  is  usually  present,  and  if  it  contains  greatly  deformed  leucocytes 
and  no  micro-organisms  is  strongly  suggestive  of  tuberculosis.  Before 
mixed  infection  the  urine  is  limpid  or  at  most  faintly  tinged  with  blood. 

The  method  of  staining  the  tubercle  bacillus  has  been  given.  The 
best  ways  of  establishing  its  presence  are  by  cultivation  on  artificial 
media  and  by  inoculation  of  the  lower  animals.  Many  examinations 
and  efforts  at  culture  are  often  required  before  the  bacillus  is  found. 

In  the  female  a  painful  zone  of  ulcerations  may  sometimes  be  seen 
at  the  meatus  urinarius,  extending  thence  up  the  urethra. 

The  general  health  suffers  as  is  the  case  in  tuberculosis  of  other 
organs.  There  is  loss  of  flesh  and  strength  and,  if  mixed  infection  is 
present,  there  is  also  chronic  septicaemia  accompanied  by  fever,  night- 
sweats,  loss  of  appetite  and  often  by  diarrhota.  In  such  cases  the  pain 
is  an  important  factor  in  producing  deterioration  of  the  general  health. 

Diagnosis. — Probably  in  a  large  majority  of  cases  tubercular 
cystitis  is  not  suspected  till  the  disease  is  well  advanced  and  has 
spread  wide  of  the  bladder.     Warren  says, — 

"  Perhaps  the  reason  that  more  than  any  other  leads  genito-uri- 
nary  tuberculosis  to  be  overlooked  is  the  readiness  to  rest  content 
with  a  diagnosis  of  'idiopathic  cystitis'  in  cases  in  which  pyuria 
and  irritable  bladder  are  the  conspicuous  symptoms,  and  in  which 
a  few  microscopic  examinations  of  the  urinary  sediment  fail  to  show 
casts,  renal  epithelium,  or  crystals,  the  latter  fact  being  often  as- 
sumed, under  these  circumstances,  to  free  the  kidneys  from  sus- 
picion of  being  involved.  '  Idiopathic  cystitis,'  in  the  sense  of  a 
spontaneously  occurring  inflammation  of  the  mucous  membrane  of 
the  bladder, — an  inflammation  without  a  well-defined  cause,  that  is 
to  say, — I  do  not  believe  exists.  If  inquiry  is  pushed  far  enough, 
some  condition  of  which  such  as  the  following  are  the  most 
famihar  examples  will  be  found  to  have  originated  the  trouble:  gon- 
orrhoea ;  stone ;  lithiasis ;  stricture ;  prostatic  hypertrophy  and  its 
consequences ;  the  use  of  instruments ;  acute  over-distention  of  the 
bladder,  such  as  occurs  sometimes  in  childbirth,  or  by  voluntary 
effort,  as  with  the  insane ;  profound  narcosis  from  opium  or  alcohol  ; 
the  ingestion  of  certain  irritating  drugs,  for  example,  cantharides ;  in 
connection  with  certain  diseases  of  the  spinal  cord,  etc. 


VESICAL   TUBERCULOSIS.  433 

"  If,  in  the  absence  of  these  or  other  well-defined  causes,  a  patient 
has  symptoms  of  cystitis,  it  is  strongly  suggestive  of  tuberculous  dis- 
ease in  the  genito-urinary  tract,  probably  located  in  the  kidneys,  the 
prostate,  the  seminal  vesicles,  or  possibly  in  the  bladder  itself;  but 
this  is  thought  to  be  rarely  the  starting-point  of  the  disease." 

Konig  states  that  half  the  patients  who  complain  of  pus  and  mucus 
in  the  urine  as  the  principal  symptom  are  tubercular ;  it  is  certainly 
the  case  that  tubercular  cystitis  is  by  no  means  a  rare  disease,  and 
that  the  bladder  is  frequently  affected,  apparently  primarily. 

There  is  no  pathognomonic  sign  or  symptom  of  tubercular  cystitis 
except  discovery  of  the  bacillus  in  the  urine.  This  is  usually  diffi- 
cult, sometimes  impossible.  Tuberculosis  should,  however,  be  sus- 
pected when  (1)  there  is  a  characteristic  family  history ;  (2)  there  have 
been  frequent  urination  and  haematuria  without  discoverable  cause ; 
(3)  cystitis  develops  and  persists  in  the  absence  of  the  ordinary  pre- 
disposing and  exciting  causes;  (4)  the  epididymis,  cord,  prostate,  or 
seminal  vesicles  show  signs  of  tubercular  involvement ;  (5)  there 
are  signs  and  symptoms  of  tuberculosis  in  other  parts  of  the  body; 
(6)  tuberculosis  is  apparently  the  only  cause  which  can  satisfactorily 
account  for  symptoms. 

The  final  diagnosis  in  the  event  of  failure  to  find  tubercle  bacilli 
in  the  urine  may  be  made  by  a  cystoscopic  examination.  The  find- 
ing of  disseminated  or  grouped  tubercles,  or  of  ragged,  irregular, 
punched-out  necrotic  ulcers,  will  be  conclusive.  It  may  happen  that 
the  appearances  are  not  typical,  that  the  infiltrated  rugse  may  simu- 
late neoplasm,  or  that  no  lesion  is  found,  though  the  bladder  is  un- 
doubtedly tubercular. 

Prognosis. — This  is  generally  bad,  though  the  disease  of  the  blad- 
der is  not  of  itself  fatal.  There  are  nearly  always  foci  in  other 
organs.  The  course  of  the  disease  is  irregular,  gradually  growing 
worse.  Death  is  generally  due  to  renal  or  pulmonary  involvement  or 
to  general  miliary  tuberculosis.  Yet  cures  have  occurred,  and  no  case 
of  tuberculosis  of  the  bladder  should  be  considered  hopeless. 

Motz  has  witnessed  eight  cases  of  complete  recovery  from  a  tuber- 
culous bladder  affection.  One  patient  was  curetted  and  five  per  cent, 
guaiacolated  oil  was  instilled ;  another  was  treated  with  instillations 
of  a  1  to  5000  bichloride  solution.  The  others  recovered  without 
local  treatment,  after  removal  of  the  tuberculous  kidney  by  nephrec- 
tomy or  its  exclusion  by  obliteration  of  the  ureter.  In  two  cases  the 
affection  was  so  severe  that  recovery  had  been  considered  hopeless. 
The  urine  contained  abundant  tubercle  bacilli. 

Treatment. — Since  vesical  tuberculosis  is  nearly  always  secondary 

28 


434  GENITO-URINARY  DISEASES  AND  SYPHILIS. 

to  renal  infection  the  treatment  consists  in  discovering  the  kidney 
involved  and  its  prompt  removal.  Thereafter  the  bladder  infection 
either  recovers  of  itself  or  is  cured  by  one  or  two  washings  with  one 
hundred  centimeters  of  a  warm  five  per  cent,  solution  of  carbolic  acid 
(Rovsing). 

When  this  radical  treatment  is  not  applicable  and  vesical  tubercu- 
losis is  recognized  in  its  early  stages,  before  the  onset  of  cystitis,  minute 
attention  to  general  hygiene,  and  the  administration  of  salol  in  small 
doses  for  the  purpose  of  keeping  the  urine  antiseptic,  represent  all 
that  should  be  done,  aside  from  the  administration  of  tonics  and  tissue- 
builders,  and  a  change  of  climate. 

It  is  particularly  important  to  avoid  instrumentation  at  this  stage  of 
the  disease  since  infection  once  started  is  practically  incurable,  and 
not  only  introduces  the  element  of  pain,  but  markedly  stimulates  the 
extension  of  the  tubercular  process. 

If,  however,  there  is  strong  reason  to  believe  that  the  tuber- 
cular infiltration  is  primary  in  the  bladder,  has  not  extended  be- 
yond this  viscus,  and  can  be  entirely  removed  by  operation,  the 
passage  of  a  cystoscope  for  the  purpose  of  corroborating  this  belief 
might  be  permissible,  but  only  on  condition  that  the  surgeon  is  pre- 
pared to  follow  this  ocular  examination  by  immediate  operation,  con- 
ducted for  the  purpose  of  entirely  removing  the  seat  of  disease. 
Unfortunately,  we  can  never  be  certain  that  tuberculosis  is  strictly 
limited  to  the  bladder,  and  we  know  by  statistical  study  that  it  is  so 
limited  in  but  a  very  small  percentage  of  cases.  Hence  this  exami- 
nation, though  theoretically  desirable,  is  practically  not  to  be  recom- 
mended. 

When  cystitis  has  developed,  the  same  strong  reason  against  the 
introduction  of  a  sound,  catheter,  or  cystoscope  does  not  obtain,  though 
the  bladder  is  often  extraordinarily  irritable,  and  a  violent  reaction 
may  be  excited  by  the  most  gentle  instrumentation. 

The  treatment  of  cystitis  is  conducted  in  accordance  with  the  prin- 
ciples already  laid  down.  Medicines  are  administered  by  the  mouth 
which  render  the  urine  bland  and  exert  a  stimulating,  healing,  and 
antiseptic  influence  upon  the  vesical  mucosa.  The  severe  pain  and 
violent  tenesmus  are  best  allayed  by  suppositories  of  opium  and 
belladonna  or  hyoscyamus  or  by  rectal  applications  through  a 
catheter,  by  means  of  a  piston  syringe,  of  fifteen  to  thirty  grains  of 
antipyrin  and  ten  to  twenty  drops  of  laudanum  dissolved  in  one-half 
ounce  of  water. 

Albarran  and  Cathelin  advise  epidural  injections  of  one-sixth  grain 
of  cocaine  in  normal  salt  solution  (10  to  30  centimeters). 


VESICAL   TUBEECULOSIS.  435. 

The  local  treatment  must  be  conducted  with  great  care.  We  have 
known  a  single  instillation  of  a  five  per  cent,  solution  of  silver  nitrate 
cause  a  degree  of  pain  and  tenesmus  which  confined  to  bed  for  weeks 
a  patient  who  until  this  was  given  had  been  comparatively  comfort- 
able. In  general  silver  nitrate  is  unsuited  to  these  cases,  and  this  fact 
is  so  well  known  that  a  prolonged  and  violent  reaction  following  its 
use  is  held  to  suggest  the  tubercular  nature  of  the  inflammation. 

The  most  successful  treatment  yet  reported  is  that  of  instillations 
of  corrosive  mercuric  chloride,  suggested  and  practised  by  Guyon. 
He  uses  a  solution  of  1  to  5000,  gradually  increasing  the  strength  up 
to  1  to  1000.  The  reaction  excited  is  usually  slight  and  transitory. 
Sometimes  it  is  severe  and  lasting. 

The  bladder  should  be  entirely  empty.  This  may  require  the  use 
of  a  catheter.  In  that  case  the  instillation  should  be  made  through 
this  instrument.  When  the  urine  contains  a  large  quantity  of  viscid 
mucus  this  will  prevent  the  medicament  from  coming  directly  in  con- 
tact with  the  mucous  membrane :  hence,  unless  there  is  extreme 
sensitiveness,  instillation  should  be  preceded  by  lavage,  great  care 
being  taken  to  avoid  painful  tension  from  injection  of  too  much  of 
the  fluid  at  one  time.  The  bladder  having  been  emptied  and  cleaned, 
from  twenty  drops  to  two  drachms  of  the  corrosive  chloride  solution 
are  instilled  and  are  allowed  to  remain  in  the  bladder.  The  initial 
dose  is  not  over  twenty  drops  of  a  solution  of  1  to  5000.  The  quan- 
tity and  strength  are  increased  carefully,  the  surgeon  being  guided  in 
this  matter  by  the  degree  of  the  pain  and  reaction  which  are  excited. 
It  is  important  to  place  the  eye  of  the  catheter  or  the  nozzle  of  the 
instillator  just  within  the  grasp  of  the  compressor  urethrse  muscle,  so 
that  the  whole  prostatic  urethra  may  be  washed  by  the  instillation, 
since  cystitis  is  always  accompanied  by  inflammation  of  this  portion 
of  the  urethral  mucous  membrane. 

The  treatment  is  repeated  daily,  or  every  second  or  third  day. 

Instillations  of  a  ten  per  cent,  mixture  of  iodoform  in  glycerin  or 
oil  have  also  been  employed,  apparently  with  beneficial  effect. 

According  to  Banzet,  twenty-nine  cases  treated  entirely  by  sub- 
limate instillations  were  cured.  Another  favorite  treatment  is  the 
injection  of  one-hundred  centimeters  of  a  warm  five  per  cent,  solution 
of  carbolic  acid.  To  this  may  be  added  one  per  cent,  iodoform.  Three 
per  cent,  to  twelve  per  cent,  watery  solutions  of  thallin  sulphate  are 
recommended  by  Keys. 

Operation  is  particularly  indicated  when  the  pain  and  urgency  be- 
come unbearable  and  are  not  controllable  by  safe  doses  of  narcotics.  ■. 
Under  these  circumstances  there  will  often  be  infiltration  of  the  pros- 


436  GENITO-UKINAET   DISEASES   AXD  SYPHILIS. 

tate  and  seminal  vesicles :  hence  complete  eradication  of  the  disease 
will  be  no  longer  practicable.  The  operation  is  then  performed  as  a 
measure  of  rehef  and  not  as  one  of  cure,  the  bladder  being  drained 
through  either  a  perineal  or  a  suprapubic  opening.  Often  this  drain- 
age gives  immediate  and  complete  relief.  Sometimes  pain  and  tenes- 
mus persist.  The  suprapubic  cystotomy  is  to  be  preferred,  since  the 
bladder  is  more  liable  to  be  opened  at  a  point  somewhat  removed 
from  the  most  active  region  of  the  tubercular  process.  A  perineal 
wound  is  very  apt  to  become  infected,  whereby  troublesome  fistulas 
are  formed. 

The  suprapubic  operation  also  possesses  the  advantage  of  allow- 
ing the  surgeon  to  inspect  the  interior  of  the  bladder  and  to  treat  di- 
rectly intravesical  lesions.  These  may  be  thoroughly  curetted  and 
well  rubbed  with  iodoform,  or  may  be  destroyed  by  the  application 
of  the  actual  cautery.  Follo\ving  these  procedures  there  are  some  re- 
ported cases  of  cure.  Were  tuberculosis  more  often  confined  to  the 
bladder,  this  form  of  intervention  would  promise  brilliant  results. 

Having  opened  and  drained  the  bladder  above  the  pubis  and  de- 
stroyed or  removed  tubercular  ulcers,  the  vesical  mucosa  is  kept  as 
clean  as  possible  by  irrigations  with  normal  salt  solution  or  a  weak 
antiseptic,  provided  it  does  not  excite  too  much  reaction.  Sometimes 
as  a  result  of  this  treatment  cystitis  is  cured  and  the  tubercular  pro- 
cess appears  to  be  checked,  the  suprapubic  opening  closing  on  re- 
moval of  the  drainage-tube.  There  is,  however,  a  constant  risk  that 
the  abdominal  wound  may  re-ulcerate  and  break  down  and  an  ab- 
dominal hernia  be  the  outcome.  In  less  favorable  cases  the  tract  of 
the  drainage-tube  often  becomes  tubercular. 

During  the  whole  course  of  local  treatment  the  importance  of 
general  hygienic  measures  must  be  remembered. 

Tuberculosis  of  the  bladder  generally  heals  after  nephrectomy.  If 
it  fails  to  do  so  within  a  year  under  ordinary  treatment  and  if  not  occu- 
pying more  than  half  the  bladder-wall,  it  should  be  excised.    (Hunnar.) 

SYPHILIS   OF   THE  BLADDER. 

Margulies  reports  three  cases  of  syphilis  of  the  bladder  charac- 
terized by  marked  cystitis  and  persistent  heematuria,  in  one  of  which 
cystoscopic  examination  disclosed  tumors  resembling  carcinoma  sur- 
rounding one  of  the  ureteral  openings,  in  another  a  small  ulcer  at  the 
base  of  the  bladder,  in  another  diffuse  cystitis ;  all  were  associated 
with  the  history  and  signs  of  tertiary  syphilis  and  all  were  cured  by 
antisyphilitic  treatment. 

Diagnosis  is  made  largely  by  exclusion.    In  the  presence  of  marked 


VESICAL  FISTULA.  43,7 

persistent  cystitis  with  haematuria,  and  the  cystoscopic  picture  of  either 
diffuse  ulcerative  or  gummatous  cystitis  stubborn  to  the  usual  treat- 
ment, together  with  the  history  and  signs  elsewhere  of  tertiary  syph- 
ilis, this  disease  may  be  suspected. 

The  local  signs  are  not  sufficiently  characteristic.  All  other  causes 
of  chronic  cystitis  and  ulceration  and  vesical  tumors  must  be  excluded. 
Finally,  the  disease  is  cured  by  energetic  antisyphilitic  treatment. 

FISTULA  OF   THE   BLADDER. 

Vesical  fistula  is  an  ulcerating  tract  leading  from  the  bladder  to 
the  surface  of  the  body  or  to  some  neighboring  viscus.  It  is  usually 
due  to  the  failure  of  a  surgical  or  an  accidental  wound  to  heal,  but  may 
be  caused  by  erosion  from  a  calculus  or  foreign  body,  burrowing  of  a 
pericystic  abscess,  or  ulceration  of  a  tubercular  or  malignant  infiltra- 
tion. The  fistulous  tract  may  run  directly  or  deviously  to  the  skin 
surface,  or  may  form  a  communication  between  the  bladder  and  the 
bowel  or  the  female  genital  tract.  The  nomenclature  of  these  fistulas 
is  indicati\^e  of  their  course  :  thus,  they  are  termed  vesico-perineal, 
vesico-hypogastric,  vesico-gluteal,  etc.  Pathologically  these  ulcerating 
channels  are  identical  with  urethral  fistulas  ;  they  may  burrow  in 
many  directions  and  open  by  several  orifices ;  they  often  develop 
lateral  blind  diverticula,  and  they  become  densely  indurated. 

Symptoms. — Cystitis  is  a  symptom  common  to  all  forms  of  long- 
standing vesical  fistula.  Other  symptoms  vary  in  accordance  with 
the  seat  of  the  extravesical  opening.  When  this  is  upon  the  skin 
surface  there  is  an  obvious  escape  of  urine. 

The  urine  may  dribble  almost  constantly  or  may  flow  intermit- 
tently. When  the  tract  is  narrow,  and  particularly  when  the  open- 
ing in  the  tract  is  valvular,  the  quantity  escaping  will  be  insignificant. 
When  conditions  the  reverse  of  these  obtain,  all  the  urine  may  pass 
through  the  abnormal  opening.  The  skin  surrounding  the  external 
opening  of  the  fistula  shows  the  excoriation,  inflammation,  and  infil- 
tration described  when  treating  of  urethral  fistulge.  During  the  act 
of  micturition,  or  when  intra-abdominal  pressure  is  increased  by 
muscular  contraction,  as  in  the  act  of  lifting,  coughing,  or  defecation, 
there  is  increased  flow  of  urine  from  the  opening. 

When  the  fistula  opens  into  the  rectum,  if  the  channel  of  com- 
munication be  narrow,  there  may  be  no  symptoms  suggesting  this 
communication  other  than  a  urinous  discharge  occurring  with  the 
passage  of  often  well-formed  stools.  Usually,  however,  the  symp- 
toms of  this  fistula  are  sufficiently  characteristic.  There  is  a  more 
or  less  constant  escape  of  urine  from  the  rectum,  and  gas  and  faeces 


438  GENITO-l/EINAKY  DISEASES  AND   SYPHILIS. 

are  passed  by  the  urethra.  We  have  seen  a  case  due  to  cancer  of 
the  bowel,  in  which  nearly  all  the  faeces  were  passed  by  the  urethra  for 
several  months.  Faecal  masses,  by  blocking  the  urethra,  often  cause 
retention  of  urine.     Cystitis  under  such  circumstances  is  very  severe. 

When  there  is  communication  between  the  bladder  and  the  small 
intestines  or  the  colon,  in  the  latter  case  usually  by  way  of  the  ap- 
pendix, gas,  remnants  of  food,  and  traces  of  bile  will  be  passed  per 
urethram,  but  the  solid  particles  found  in  the  urine  probably  will  not 
exhibit  the  characteristics  of  faeces.  There  will  be  no  urine  escaping 
by  the  rectum,  or  none  which  can  be  recognized  as  such,  since  it  is 
thoroughly  mixed  with  the  rectal  contents. 

Diagnosis. — When  the  fistula  opens  externally  the  diagnosis  is 
based  on — 1,  escape  of  urine,  particularly  marked  during  abdominal 
straining ;  2,  escape  of  colored  fluids  injected  into  the  bladder  or  methy- 
lene blue  by  mouth  ;  3,  urethral  examination,  a  sound  being  passed  into 
the  bladder  and  a  fine  probe  being  introduced  along  the  fistulous  tract ; 
4,  cystoscopic  examination  ;  5,  injection  of  hydrogen  peroxide  along  the 
fistulous  tract,  bubbles  then  escaping  per  urethram  at  the  next  act  of 
micturition  ;  6,  palpation,  an  area  of  induration  sometimes  being  per- 
ceptible from  the  external  opening  directly  to  the  bladder-wall. 

When  the  fistulous  opening  is  tortuous  and  narrow,  exploration 
with  a  probe  is,  of  course,  impossible. 

When  the  fistula  opens  into  the  bowel  the  diagnosis  may  be  more 
difficult.  The  passage  of  air  at  the  end  of  micturition  and  with  a 
bubbhng  sound  is  in  itself  pathognomonic.  The  detection  of  frag- 
ments of  partially  digested  food  or  of  faecal  masses  in  the  urine,  the 
finding  of  urinary  salts  in  the  liquid  passed  per  anum,  the  detec- 
tion of  an  opening  into  the  rectum  by  direct  examination  through  a 
speculum,  the  finding  of  a  bladder-opening  by  the  cystoscope,  and 
particularly  the  discovery  of  a  sufficient  cause  for  such  a  lesion,  as, 
for  example,  malignant  or  tubercular  ulceration,  or  large  stone,  or  ap- 
pendicitis, would  lead  to  a  correct  diagnosis.  Colored  solutions,  such 
as  methyl-blue,  if  injected  into  the  bladder,  may  appear  in  the  stools, 
or  if  administered  by  mouth  will  appear  along  the  fistulous  tract,  thus 
positively  establishing  the  existence  of  a  vesico-rectal  fistula. 

The  differential  diagnosis  between  vesical  and  urethral  fistula  is 
based  upon  the  fact  that  urine  escapes  from  the  latter  only  during  or 
after  micturition,  and  that  colored  fluids  injected  into  the  bladder  will 
not  escape  through  the  fistulous  opening  until  the  patient  urinates. 

Treatment. — Fistulas  due  to  tubercular  and  malignant  infiltration 
and  ulceration  are  incurable.  The  appropriate  treatment  is  that  di- 
rected against  the  cystitis.     Perineal  or  suprapubic  drainage  may  be 


VESICAL   FISTULA.  439 

required.  Fistula  following  stone  operation,  if  small  and  comparatively 
recent,  may  be  cured  by  continuous  catheterization,  combined  with 
antiseptic  washing  of  the  bladder  and  cauterization  of  the  fistulous 
tract,  preferably  with  the  galvano-cautery.  If  after  this  treatment 
the  fistula  persists,  permanent  catheterization  continued  for  two  or 
three  weeks  may  be  tried.  This  failing,  the  fistula  should  be  laid 
open  to  the  bladder,  its  walls  dissected  out,  and  the  wound  treated  as 
it  would  be  after  the  operation  of  lithotomy. 

When  the  fistula  opens  in  the  gluteal  region  or  in  the  neighbor- 
hood of  the  hip-joint,  after  a  preliminary  effort  at  closure  by  catheter- 
ization median  perineal  lithotomy  should  be  performed,  and  the 
bladder  should  be  drained  immediately  through  this  opening. 

Small  recto-vesical  flstulse  not  due  to  tubercular  or  malignant  in- 
filtration are  treated  on  the  same  general  principles.  At  first  cathe- 
terization should  be  tried,  combined  with  cauterization  of  the  fistulous 
tract  through  the  rectum,  after  which  a  permanent  catheter  should  be 
worn  with  the  patient  in  ventral  decubitus. 

This  failing,  if  the  tract  is  extraperitoneal, — that  is,  if  it  hes  below 
the  recto-vesical  peritoneal  fold, — it  may  be  operated  on  as  described 
in  the  treatment  of  urethro-rectal  fistula. 

When  the  fistulous  tract  is  intraperitoneal  and  when  it  persists  in 
spite  of  the  palliative  means  described,  a  formal  operation  is  indicated, 
since  the  ultimate  outlook  of  these  cases  if  untreated  is  absolutely  bad, 
death  resulting  from  ascending  nephritis.  Immediately  preceding  the 
operation  the  bladder  should  be  thoroughly  irrigated  with  dilute  anti- 
septics, preferably  corrosive  mercuric  chloride  1  to  5000  containing 
one-half  of  one  per  cent,  of  carbohc  acid.  This  is  followed  by  irrigation 
of  silver  nitrate  1  to  500.  The  peritoneum  is  then  opened  just  above 
the  pubis,  the  communication  between  the  bowel  and  the  bladder  is 
rendered  accessible,  and  the  intraperitoneal  operative  area  is  packed 
off  from  the  general  peritoneal  cavity  by  gauze  sponges  ;  the  bowel  is 
then  dissected  loose,  the  opening  into  it  is  closed  by  Lembert  sutures, 
and  the  bladder-wound  is  closed  by  a  double  row  of  catgut  sutures, 
the  first  continuous  and  including  all  its  coats  except  the  epithelial 
layer  of  the  mucous  membrane,  the  second  interrupted  (Lembert) 
and  including  only  the  peritoneal,  muscular,  and  submucous  invest- 
ments. This  operation  is  always  dangerous,  since  the  bladder  is 
invariably  infected,  and  peritonitis  may  result. 

In  the  after-treatment  the  bladder  is  drained  for  from  three  to  five 
days  by  permanent  catheterization,  and  is  irrigated  twice  daily  with 
lotions  of  silver  nitrate  1  to  2000,  boric  acid  four  per  cent.,  or  salicyhc 
acid  one-half  per  cent. 


CHAPTER  XII. 

CALCULUS  OF  THE  BLADDER. TUMORS  OF  THE  BLADDER. 

Vesical  calculus  is  a  concretion  of  the  solid  urinary  constituents 
of  such  size  or  so  placed  that  it  does  not  escape  through  the  normal 
passages,  but  remains  in  the  bladder. 

Calculi  may  be  generally  grouped  under  the  following  headings  : 

1.  Those  formed  from  the  normal  constituents  of  the  urine, — uric 
acid,  the  phosphatic,  the  mixed,  and  the  urate  calcuh. 

2.  Calculi  formed  of  salts  found  in  normal  urine,  but  never  present 
in  excess  except  in  disease, — the  oxalates  and  carbonates. 

3.  Concretions  formed  from  elements  entirely  foreign  to  normal 
urine, — cystin,  indigo,  and  xanthic  oxide. 

The  large  majority  of  stones  are  formed  of  uric  acid  and  the 
urates  ;  the  phosphatic  and  mixed  calculi  come  next  in  order  of 
frequency  ;  and  last  come  the  oxalates  and  rarer  forms, — indigo,, 
xanthic  oxide,  etc. 

Uric  acid  calculi  are  formed  in  acid  urine.  Originating  in  the 
pelvis  of  the  kidney,  they  descend  through  the  ureter  to  the  bladder, 
usually  causing  that  form  of  violent  and  paroxysmal  pain  which  is 
termed  renal  colic.  Once  in  the  bladder  their  further  gro^^iih  is  due 
to  accretion  of  uric  acid  alone,  or  they  may  form  nuclei  for  the  de- 
position of  other  elements.  Uric  acid  calculi  are  generally  smooth, 
spheroidal,  moderately  hard,  and  yellow  to  reddish  brown  in  color. 

High  living  and  a  gouty  diathesis  are  factors  predisposing  to  the 
formation  of  these  concretions.     They  occur  at  the  extremes  of  life. 

Urate  Calculi. — The  sodium,  potassium,  and  ammonium  urates, 
though  rarely  forming  large  stones,  are  constantly  and  copiously  de- 
posited as  sediment  in  febrile  affections,  and  when  from  any  cause 
the  urine  becomes  markedly  concentrated.  The  urate  calcuh  are  ob- 
served almost  exclusively  in  children.  In  the  adult  they  may  form 
the  nuclei  of  large  concretions  made  up  of  divers  elements.  They 
are  grayish  yellow  in  color. 

Phosphatic  calculi  follow  the  uric  acid  and  urate  concretions  in 
order  of  frequency ;  there  are  three  varieties. 

1.  The  amorphous  calcium  phosphate  rarely  forms  a  calculus  of 
itself.     It  is  commonly  deposited  in  layers  about  calcuh  of  other  salts,. 


CALCULUS  OF  THE  BLADDER.  44I 

or  is  intermingled  with  them,  sometimes  reaching  considerable  size. 
It  crumbles  easily  ;  its  color  is  a  dirty  brown  or  white. 

2.  The  triple  phosphates  (ammonio-magnesian  phosphates)  are 
commoner  in  calculus  formation  than  calcium  phosphate.  Such  cal- 
culi are  crystalline  and  of  a  whitish  color.  Formed  in  ammoniacal 
urine  only,  they  are  vesical  in  origin  and  frequently  complicate  cystitis. 

3.  Mixed  fusible  calcuh,  being  composed  of  the  triple  phosphates 
and  calcium  phosphate,  are  not  uniform  throughout,  forming  about  a 
nucleus  of  calcium  oxalate,  uric  acid,  foreign  bodies,  etc.  They  ap- 
pear as  masses  which  resemble  white  friable  mortar,  and  are  formed 
in  ammoniacal  urine. 

Calcium  oxalate  calculi,  like  those  of  uric  acid,  are  of  renal  ori- 
gin, and  occur  most  frequently  in  patients  suffering  from  oxaluria,  a 
diathesis  associated  with  indigestion  and  neurasthenia.  These  are  the 
hardest  of  all  stones,  and  are  usually  small  or  of  medium  size,  sphe- 
roidal in  shape,  dark  brown  or  black  in  color,  and  have  a  tuberculated 
surface,  giving  rise  to  the  name  of  mulberry  calculus.  Amorphous 
urates  and  phosphates  are  often  deposited  between  the  tubercu- 
lations. 

Calcium  carbonate  calculi  are  rare.  When  found  they  have  been 
mu\tiple,  small,  weighing  from  thirty  to  forty  grains  each,  and  hard 
and  lamellar  in  structure,  similar  to  the  calcium  oxalate  calcuh. 

Cystin  Calculi. — Cystin  as  a  major  constituent  of  calculus  is  ex- 
tremely rare.  As  is  the  case  with  the  uric  acid  and  calcium  oxalate 
calculi,  cystin  concretions  originate  in  the  kidney.  In  appearance 
they  are  irregular  and  knotty,  sections  showing  no  attempt  at  crystal- 
Hzation,  waxy  and  yellowish  white  at  first,  but  turning  to  green  after 
long  exposure  to  the  air.  ' 

Xanthin  is  another  rare  constituent  of  calculus.  Indigo  does  not 
form  a  calculus  in  itself,  but  may  be  so  important  an  ingredient  that 
it  gives  the  stone  its  typical  color.  It  occurs  in  cases  of  liver  disease 
associated  with  cystitis. 

A  calculus  is  named  from  its  preponderating  element,  but  usually 
there  is  found  one  salt  serving  as  a  nucleus,  with  layers  of  different 
salts  superimposed.  Thus,  the  phosphatic  calculus  is  often  found  to 
have  in  its  centre  a  minute  concretion  of  calcium  oxalate  or  uric 
acid.  On  dissolving  out  the  salts  of  even  the  smallest  calculus  there 
will  be  found  an  albuminoid  or  colloid  framework  upon  which  these 
have  crystallized,  and  which  serves  to  agglutinate  the  mass.  Rainey 
and  Ord  have  demonstrated  the  tendency  of  crystalline  salts  when  in 
solution  with  colloid  or  albuminoid  substances  to  assume  rounded  or 
spheroidal  forms  in  crystallization.     It  is  certain  that  the  development 


442  genito-uei:n'aey  diseases  and  syphilis. 

of  stone  is  not  wholly  due  to  the  mere  presence  of  an  excess  of  any  of 
the  urinary  salts,  for  copious  deposits  of  uric  acid  and  the  phosphates 
may  exist  for  years  without  any  evidence  of  calculus  formation. 

If,  however,  at  a  time  when  the  urinary  salts  are  in  excess,  any 
renal  or  vesical  irritation  is  lighted  up,  by  means  of  which  blood  and 
serum  are  intermingled  with  the  urine,  furnishing  an  albuminoid  sub- 
stance which  favors  the  agglutination  of  the  small  crystals,  calcuH  may 
form,  and,  once  formed,  tend  to  increase  in  size. 

Vesical  calcuH,  when  free,  are  usually  spheroidal.  They  may  be 
irregular  from  multipHcity  and  erosion,  or  from  having  been  moulded 
in  a  diverticulum  or  in  the  prostatic  urethra.  Ord  holds  that  calculi 
split  spontaneously  because,  incident  to  changes  in  the  specific  gravity 
of  the  urine,  the  cohoid  framework  becomes  swollen  by  absorption 
of  a  Hquid  of  different  density,  and  the  concretions  fracture  along  the 
lines  of  deposition  upon  this  framework. 

Etiology. — It  is  evident  that  for  calculi  to  form  two  main  factors 
are  requisite :  first,  a  diathetic  tendency  to  over-elimination  of  the 
urinary  solids  which  form  the  basis  of  calculi ;  and,  second,  local  con- 
ditions which  cause  these  solids  to  conglomerate. 

The  diathetic  tendency  is  strongly  marked  in  certain  localities, 
but  these  are  so  wide-spread,  so  totally  different  in  climate  and  sur- 
roundings, and  the  diet  and  habits  of  the  people  so  differ,  that  no 
general  law  can  be  deduced  which  bears  on  calculus  formation. 

There  is  a  popular  behef  that  a  hmestone  soil  which  furnishes 
hard  drinking-water  predisposes  to  calculus ;  but,  although  the  dis- 
ease is  quite  common  in  many  limestone  districts,  it  is  equally  com- 
mon in  sandstone  districts ;  moreover,  there  is  no  reason  why  the 
ingestion  of  lime  should  cause  uric  acid  deposits.  Vesical  calculi  are 
found  in  cold  as  well  as  in  warm  countries ;  for  instance,  in  Southern 
China  and  in  Northern  Scotland.  They  are  more  frequent  in  the 
central  United  States  than  in  New  England  and  the  Southern  States, 
and  one  section  of  a  single  State  may  furnish  more  cases  than  another. 
Urinary  calculi  are  found  from  extreme  youth,  even  in  the  foetal 
bladder,  to  old  age. 

In  the  statistics  of  Civiale,  Coulson,  and  Thompson,  compiled  from 
10,467  cases,  62.33  per  cent,  occurred  in  persons  under  twenty  years 
of  age ;  these  cases  were  taken  from  hospital  patients  representing 
the  poorer  classes.  Sir  Henry  Thompson,  in  a  series  of  private  cases 
numbering  798,  operated  for  vesical  calculus  93  times  in  patients 
between  the  ages  of  sixteen  and  fifty  years ;  527  times  in  patients 
ranging  between  fifty  and  seventy ;  175  times  in  patients  over  seventy ; 
and  but  3  times  in  patients  under  sixteen. 


CALCULUS  OF  THE  BLADDER.  443 

He  believes  that  calculi  are  so  frequently  found  in  hospital  and 
charity  practice  in  patients  under  twenty  years  of  age  because  of  the 
bad  hygienic  surroundings,  irregular  diet,  and  malnutrition  of  chil- 
dren in  the  lower  walks  of  life. 

He  accounts  for  more  than  sixty-six  per  cent,  of  his  private  cal- 
culus patients  being  over  fifty  years  of  age  on  the  ground  that  the 
upper  and  middle  classes  of  society  are  predisposed  to  the  uric  acid 
diathesis  after  the  age  of  fifty,  because  then  vital  activity  diminishes, 
and  consequently  comes  the  desire  for  rest  and  a  sedentary  life,  with- 
out commensurate  lessening  of  the  quantity  and  variety  of  food  in- 
gested. It  w^ould  therefore  seem  that  insufficient  clothing,  lack  of 
proper  nourishment,  and  improper  hygienic  surroundings  among  chil- 
dren predispose  to  calculus-formation,  while  among  adults  the  same 
effect  is  produced  by  conditions  of  a  very  different  character. 

The  relative  difference  in  the  length  and  dilatability  of  the  male 
and  the  female  urethra  probably  explains  the  greater  frequency  of  cal- 
culus in  men.  A  small  uric  acid  stone  reaching  the  female  bladder 
has  little  tendency  to  linger  there,  the  short,  wide  urethra  allowing 
it  to  pass  without  producing  even  a  sensation  of  uneasiness.  The 
vesical  calculi  observed  in  women  are  usuahy  incrustations  about  a 
foreign  body.  The  proportion  of  calculi  found  in  the  female  bladder 
as  compared  to  the  male  bladder  is  about  one  to  twenty-two. 

Symptoms. — Preceding  the  formation  of  a  stone  there  may  have 
been  a  history  of  gravel,  of  oxaluria,  of  heavy  deposits  of  urates. 
When  the  stone  is  of  uric  acid  and  is  formed  in  the  kidney,  lumbar 
pains,  hsematuria,  and  renal  colic  often  precede  its  arrival  in  the 
bladder.  It  may,  however,  reach  this  viscus  without  exciting  the 
slightest  symptom. 

Having  reached  the  bladder,  the  stone  acts  as  a  sterile  foreign 
body,  producing  irritation  and  congestion,  and  thus  favoring  the  de- 
velopment of  cystitis.  Frequent  micturition,  pain,  hsematuria,  and 
reflex  disturbances  are  the  prominent  symptoms. 

Frequent  Urination. — This  symptom  is  most  marked  in  the  day- 
time :  it  is  aggravated  by  motion,  and  reheved  by  rest.  The  desire 
to  urinate  comes  suddenly  and  is  almost  irresistible.  The  patient 
may  be  compelled  to  urinate  every  two  or  three  hours,  or  in  some 
cases  even  every  few  minutes.  The  act  of  urination  is  often  ac- 
companied by  much  tenesmus,  in  which  the  rectum  participates,  so 
that  prolapse  of  the  bowel,  particularly  in  children,  is  by  no  means 
uncommon.  A  smah  stone  irregular  in  shape  produces  a  more  aggra- 
vated condition  of  frequent  urination  than  a  large,  smooth  calculus. 
An  encysted  or  adherent  stone,  or  one  which  hes  at  the  base  of  a 


444  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

bladder  so  changed  in  shape  that  the  calculus  is  not  liable  to  come  in 
contact  with  the  vesical  neck,  will  often  give  rise  to  no  marked  fre- 
quency of  urination.  It  is  to  be  noted  that  frequent  urination  is  a 
symptom  of  so  many  other  bladder  conditions  that  in  itself  it  does 
not  necessarily  suggest  the  presence  of  stone. 

Exceptionally  there  is  sudden  stoppage  during  the  passage  of  a 
full-sized  stream.  This  is  observed  chiefly  in  young  persons  and  in 
patients  having  small  stones,  since  it  is  due  to  the  dropping  forward 
of  the  calculus  into  the  vesical  orifice  of  the  urethra.  It  is  extremely 
suggestive  of  calculus  if  it  can  be  obviated  by  the  patient  urinating  in 
certain  positions,  as,  for  instance,  when  lying  on  the  back.  As  with 
frequent  micturition,  sudden  interruption  of  the  stream  is  a  symptom 
of  inflammatory  troubles  of  the  vesical  neck,  and  is  not  pathogno- 
monic of  stone. 

Pain. — The  pain  of  vesical  calculus  is  usually  referred  to  the 
lower  urethral  surface,  about  an  inch  posterior  to  the  glans.  It  is 
burning  and  stinging  in  character,  and  is  less  pronounced  in  old  men 
than  in  children,  prostatic  enlargement  in  the  former  preventing  the 
calculus  from  coming  in  contact  with  the  vesical  neck. 

Pain  is  most  marked  at  the  end  of  urination,  because  then  the 
inflamed  mucous  membrane  is  brought  in  direct  contact  with  the 
stone.  The  intensity  of  pain  varies  proportionately  to  the  degree  of 
cystitis  and  the  size  and  nature  of  the  stone,  and  is  intensified  by 
jarring  motions  and  by  change  in  position.  Small  stones,  especially 
if  they  are  rough,  cause  more  suffering  than  do  large  ones.  A  history 
of  pain  pronounced  during  the  early  stages  of  stone,  and  gradually 
lessening,  suggests  that  a  small  rough  stone  has  become  covered  with 
mucus  or  with  phosphatic  deposits,  thus  forming  a  smooth  surface. 
A  stone  may  be  carried  for  years  without  exciting  the  slightest  pain. 

Scematuria  is  of  importance  only  when  associated  with  other 
symptoms.  It  is  caused  by  the  mechanical  friction  and  scratching  of 
the  calculus,  and  is  most  pronounced  when  the  bladder  is  congested, 
as  in  cystitis.  It  is  markedly  aggravated  by  motion.  The  blood  is 
most  apt  to  be  voided  towards  the  close  of  urination. 

Reflex  Disturbances. — Priapism  has  been  noted  as  a  reflex,  par- 
ticularly in  children ;  in  them  it  may  lead  to  the  practice  of  mastur- 
bation, since  pain  is  referred  to  the  end  of  the  penis,  and  there  is 
commonly  pulling  and  handling  of  that  organ  in  instinctive  efforts  to 
obtain  relief.  Reflex  pains  felt  in  the  rectum,  the  perineum,  the 
hypogastric  region,  the  small  of  the  back,  and  on  the  outer  surface  of 
the  thighs,  the  lower  leg,  or  the  foot,  are  frequently  noted.  There  is 
a  peculiar  pain  in  the  foot,  known  as  podalgia,  which  is  sometimes 


Fig.  135. 


Large  vesical  calculus.     (Skiagraph  made  by  Dr.  IT.  K.  Pancoast.) 


CALCULUS  OF  THE  BLADDEK.  445 

symptomatic  of  stone  ;  it  is  frequently  located  in  the  neighborhood 
of  the  ball  of  the  great  toe,  but  may  extend  over  the  whole  sole.  It  is 
most  commonly  observed  in  the  gouty  and  rheumatic.  It  disappears 
as  soon  as  the  calculus  is  removed.  Pain  may  also  be  felt  in  the 
upper  extremities  of  the  lungs. 

Rectal  prolapse,  hemorrhoids,  and  subconjunctival  hemorrhage, 
though  not  absolute  in  their  significance,  may  aid  in  diagnosis,  since 
they  are  symptomatic  of  the  violent  straining  efforts  v\rhich  frequently 
accompany  the  act  of  urination. 

True  inflammation  of  the  bladder  is  likely  to  occur  sooner  or 
later,  though  some  cases  of  stone  may  last  indefinitely  without  this 
complication.  It  is  usually  caused  by  instrumentation  ;  but  the  in- 
tervention of  this  agency  is  not  necessary  for  its  development.  It 
aggravates  the  symptoms  already  given,  and  causes  a  heavy  deposit 
of  muco-pus  in  the  urine. 

Diagnosis. — The  diagnosis  of  stone  is  founded  upon  physical 
examination.  The  symptoms  above  described,  either  singly  or  alto- 
gether, may  be  excited  by  any  inflammation  or  irritation  at  the  neck 
of  the  bladder  independent  of  its  cause.  Pain  referred  to  the  under 
surface  of  the  glans  penis  and  felt  most  acutely  at  the  end  of  urina- 
tion, sudden  interruption  of  the  full  stream,  relieved  by  change  of 
posture  and  not  occurring  when  certain  postures  are  assumed,  and 
hsematuria,  can  be  considered  only  as  strongly  suggestive  of  stone 
and  as  calling  for  direct  examination. 

A  vesical  calculus  may  excite  no  symptoms.  Morris  records  the 
case  of  a  man  who,  at  the  age  of  sixty-six,  learned  by  an  attack  of 
heematuria  that  he  had  vesical  calculus.  This  patient  died  after 
thirteen  years,  of  carbuncle  of  the  neck.  He  never  had  a  bladder- 
symptom,  and  his  first  attack  of  haematuria  was  also  the  last,  although 
he  never  submitted  to  operation. 

The  examination  is  conducted — 1,  by  bimanual  palpation;  2,  by 
intravesical  exploration  with  instruments,  including  (a)  stone-searcher 
or  sound;  (6)  lithotrite ;  (c)  evacuator  attached  to  aspirator;  {d) 
cystoscope  ;  3,  by  direct  examination  of  the  bladder  through  either 
a  perineal  or  a  suprapubic  opening ;  4,  by  X-ray  examination. 

1.  Bimanual  palpation  is  thus  practised  in  the  male :  the  patient 
having  passed  his  water  is  directed  to  lean  well  forward  over  the  back 
of  an  arm-chair,  for  instance,  with  the  legs  moderately  separated  and 
the  abdominal  muscles  relaxed.  The  surgeon  then  introduces  one 
or  two  fingers  of  the  right  hand  into  the  rectum  and  with  the  four 
fingers  of  the  left  hand  presses  upward  and  backward,  directly  over 
the  pubis,  towards  the  base  of  the  bladder.     In  place  of  standing, 


446  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

the  patient  may  lie  on  his  back,  the  head  and  shoulders  elevated, 
the  thighs  flexed ;  the  right  and  left  hands  are  used  as  just  described. 
In  thin  subjects  and  in  those  with  not  too  muscular  abdominal  walls, 
the  presence  or  absence  of  calculus  of  even  small  size  can  be  readily 
determined. 

In  the  female  examination  is  made  through  the  vagina,  the  bladder 
being  palpated  by  the  ordinary  bimanual  manipulation. 

2.  Instrumental  exploration  is  inaugurated  by  passing  a  stone- 
searcher.  The  requirements  of  a  satisfactory  vesical  sound  or  stone- 
searcher  are  that  it  should  have  a  straight  shaft  fully  ten  inches  long, 
and  a  short  curve  near  the  tip.  Two  instruments  should  be  provided, 
one  with  a  very  slight  curve,  the  other  with  an  abrupt  curve,  permit- 
ting it  to  be  carried  into  the  pouch  behind  the  prostate.  The  calibre 
should  be  about  13  F.  (Fig.  136.)  It  is  desirable  to  begin  the  exami- 
nation with  the  bladder  fully  distended,  and  to  allow  the  urine  gradu- 

FiG.  136. 


stone-searcher. 


ally  to  escape,  the  search  being  continued.  For  this  reason,  and  be- 
cause it  allows  of  an  approximate  estimation  of  the  size  of  the  stone, 
Thompson's  stone-searcher  is  particularly  serviceable.      (Fig.  137.) 


Fig.  137. 


Thompson's  stone-searcher. 

The  solid  steel  sounds  shaped  as  already  described,  and  provided 
with  flat  handles,  are  the  instruments  of  choice. 

These  sounds  are  passed  with  the  patient  in  a  recumbent  or  semi- 
recumbent  position,  with  shoulders  raised  and  thighs  flexed  and  sepa- 
rated. Should  cystitis  not  be  present  it  is  particularly  important  to 
conduct  all  manipulations  in  accordance  with  the  rules  already  laid 
down  for  antiseptic  instrumentation  of  the  urethra  and  the  bladder, 
since  it  is  now  universally  recognized  that  the  passage  of  instruments 
is  probably  the  most  prolific  cause  of  bladder-infection.  The  instru- 
ment, having  been  sterilized  and  lubricated,  is  introduced  without  dif- 
ficulty if  th«  operator  remembers  that  its  curve  does  not  correspond 


CALCULUS  OF  THE  BLADDEE.  447 

with  the  fixed  curve  of  the  normal  urethra ;  at  the  time  the  extremity 
of  the  instrument  traverses  this  region  downv^ard  pressure  must  be 
made  with  the  fingers  on  each  side  of -the  penis,  so  as  to  elongate  and 
straighten  out  the  urethral  curve.  Even  after  the  sound  has  traversed 
the  membranous  urethra  it  is  often  arrested  at  the  internal  vesical 
sphincter,  and  when  in  this  position  a  comparatively  roomy  prostatic 
urethra  may  allow  of  some  degree  of  lateral  motion.  It  is  important 
to  remember  that  the  sound  is  not  satisfactorily  introduced  into  the 
adult  bladder  unless  at  least  eight  inches  of  the  straight  shaft  have 
been  passed,  and  that  when  it  has  properly  entered  it  can  be  easily 
rotated  almost,  jf  not  quite,  around  its  long  axis. 

The  bladder  having  been  entered,  the  cavity  of  this  viscus  should 
be  systematically  explored.  The  sound  is  partly  withdrawn  and 
pushed  back  again  with  comparatively  rapid  motions,  the  handle  being 
elevated  and  depressed.  The  withdrawal  is  at  no  time  sufficient  to 
engage  the  curve  of  the  instrument  in  the  prostatic  urethra.  The 
back  of  the  sound  should  then  be  turned  towards  one  side  of  the 
bladder,  and  the  point,  directed  towards  the  opposite  side,  should  be 
made  to  traverse  the  arc  of  a  circle,  sweeping  transversely  through 
the  bladder  from  above  downward.  This  motion,  begun  with  the 
inner  end  of  the  sound  at  the  bas-fond,  is  continued  while  the  sound 
is  gently  drawn  outward  until  the  curve  reaches  the  vesical  neck.  It 
is  then  pushed  in  again  until  the  posterior  wall  of  the  bladder  is 
touched.  The  point  is  now  turned  to  the  opposite  side  and  the  same 
mancEuvre  is  repeated.  If  the  stone  is  not  found  in  this  manner,  the 
searcher  is  again  introduced  to  its  full  length,  and  the  tip  is  turned 
gently  towards  the  floor  of  the  bladder,  and  rotated  quickly  from 
side  to  side,  while  the  instrument  is  gradually  withdrawn  until  its 
curve  catches  the  vesical  neck.  The  anterior  wall  of  the  bladder  may 
be  explored  by  pressing  it  down  by  suprapubic  pressure  till  the  tip  of 
the  instrument  can  reach  its  surface.  Where  there  is  an  enlarged 
prostate  and  the  base  of  the  bladder  is  depressed,  it  is  well  to  elevate 
this  portion  of  the  viscus  by  a  finger  introduced  into  the  rectum, 
while  the  exploration  with  the  sound  is  continued. 

If  these  manipulations  fail  to  detect  the  stone,  the  urine  should 
be  gradually  withdrawn,  and  as  the  bladder  contracts  they  should 
be  repeated,  Thompson's  searcher  should  be  used  under  such  cir- 
cumstances. 

The  presence  of  stone  is  denoted  by  a  distinct  click,  which  can  be 
both  felt  and  heard.  The  feeling  is  that  of  a  sound  coming  in  contact 
with  a  hard  body,  the  click  like  that  of  a  piece  of  metal  striking  the 
sound.    It  is  important  to  bear  in  mind  that  this  click  should  be  heard 


448  GENITO-UKINAKY  DISEASES  AND   SYPHILIS. 

and  not  merely  felt.  The  attachment  of  sounding-boards  or  of  tubes 
to  the  searcher  is  of  no  practical  help  to  the  surgeon  himself,  though 
both  are  useful  for  class  demonstration.  Suprapubic  auscultation  is 
said  to  be  helpful. 

The  size  of  the  stone  may  be  estimated  by  a  searcher  provided 
with  markings  on  its  shaft  and  with  a  sliding  collar.  (Fig.  137.)  By 
passing  this  collar  to  the  meatus  after  the  stone  is  first  touched,  and 
then  marking  the  point  at  which  the  sound  ceases  to  come  in  contact 
with  it  as  it  is  slowly  withdrawn,  the  diameter  of  the  stone  may  be 
determined,  this  being,  of  course,  the  distance  between  the  collar  and 
the  meatus. 

The  surgeon  may  either  fail  to  detect  a  stone  which  is  present  or 
imagine  he  has  detected  a  stone  which  is  not  present.  Failure  to 
detect  a  stone  which  is  present  may  be  due  to — 1,  the  more  or  less 
encysted  condition  of  the  calculus,  leaving  little  or  none  of  its  surface 
exposed  ;  2,  the  presence  of  a  diverticulum  with  a  very  small  opening 
containing  the  stone ;  3,  the  fixation  of  the  stone  to  the  summit  or 
the  anterior  wall  of  the  bladder  by  adhesions  ;  4,  the  covering  of  the 
stone  with  lymph  or  blood-clot ;  5,  the  lodgement  of  the  stone  in  a 
deep  post-prostatic  sinus  or  between  the  lateral  or  upper  walls  of 
a  prostatic  overgrowth  and  the  vesical  mucosa  ;  6,  failure  to  enter  the 
bladder  with  the  sound,  the  prostatic  urethra  being  dilated  and  the 
vesical  orifice  of  this  canal  being  obstructed  by  prostatic  overgrowth. 

The  surgeon  may  believe  that  he  has  detected  stone  when  none 
is  present  from — (1)  incrustation  of  a  tumor  with  lime  salts ;  (2)  a 
fasciculated  condition  of  the  bladder,  especially  when  associated  with 
ulceration  and  partial  incrustation ;  (3)  possible  bony  growths  de- 
veloped from  the  pelvis  ;  tumors  ;  faecal  impaction  in  the  rectum  ;  and 
undue  prominence  of  the  promontory  of  the  sacrum. 

Examination  by  the  lithotrite  is  of  advantage  in  enabling  the  sur- 
geon to  determine  the  exact  size  of  the  stone,  to  ascertain  whether  or 
not  it  is  adherent,  and  to  make  a  rough  estimate  of  its  hardness.  As 
a  means  of  simply  detecting  the  stone  it  is  no  more  serviceable 
than  a  stone-searcher  of  similar  curve,  and  is  more  difficult  of 
manipulation. 

The  evacuating-tube  attached  to  an  evacuator  is  probably  the  best 
stone-searcher  if  the  calculus  is  very  small.  As  the  liquid  in  the 
evacuator  is  driven  forcibly  in  and  then  aspirated,  the  small  calculus 
will  be  brought  against  the  opening  of  the  catheter  Avith  a  sharp  and 
unmistakable  click.  It  should  be  noted  that  if  the  eye  of  the  tube 
is  carried  too  near  the  vesical  wall  this  will  be  sucked  in  and  will  give 
a  jarring  sensation,  or  if  the  joints  of  the  instrument  are  loose  there 


CALCULUS  OF  THE  BLADDEK.  449 

may  be  produced  a  sound  which  will  closely  simulate  the  click  of  a  stone. 
This  instrument  is  useless  when  the  stone  is  encysted  or  adherent. 

An  examination  with  a  cystoscope  is  of  service  as  a  means  of 
finding  stones  which  cannot  be  reached  by  the  sound,  corroborating- 
diagnosis,  determining  whether  a  stone  is  adherent  or  encysted,  and 
discovering  the  condition  of  the  vesical  mucosa. 

Because  of  the  thoroughness  with  which  the  bladder  can  be 
explored  by  the  cystoscope,  direct  examination  through  a  peri- 
neal opening  will  be  rarely  required,  even  in  obscure  cases,  except 
when  the  stone  is  encysted  or  when  the  concomitant  disease  of  the 
bladder  is  so  inveterate  and  pronounced  that  prolonged  drainage  is 
indicated.  In  such  cases  the  stones  are  usually  encrusted  with 
phosphates,  and  should  be  detected  by  skiagraphy.  The  suprapubic 
route  is  the  one  of  choice  when  an  incision  is  required  for  diagnostic 
purposes. 

It  is  apparent  that  the  diagnosis  of  calculus  is  founded  solely  on 
direct  examination. 

Aside  from  containing  a  small  quantity  of  blood  and  perhaps  an 
excess  of  deposits,  the  urine  may  remain  for  a  long  time  normal 
Stone  in  itself  will  not  cause  cystitis.  It  simply  predisposes  to  infec- 
tion. When  infection  has  taken  place,  often  from  the  introduction 
of  a  sound  or  other  instrument  into  the  bladder,  all  the  symptoms 
are  aggravated.  Pain  becomes  more  severe  and  constant,  frequency 
and  urgency  of  urination  are  more  pronounced,  bleeding  is  freer, 
and  tenesmus  is  more  distressing.  It  is,  however,  clear  that  these 
symptoms  are  indicative  rather  of  cystitis  than  of  stone. 

Prognosis. — A  vesical  calculus  may,  in  the  absence  of  cystitis, 
from  the  frequency  and  difficulty  of  micturition,  cause  hypertrophy 
and  thickening  of  the  bladder-walls,  dilatation  of  the  ureters  and 
kidney  pelves,  and  a  chronic  congestion  of  the  whole  urinary  tract, 
strongly  favoring  infection.  Cystitis  once  started  is  constantly  aggra- 
vated, and  may  extend  deeply.  Exceptionally  the  calculus  ulcerates 
through  the  vesical  walls,  forming  a  pericystic  abscess. 

Roy  den  records  the  case  of  a  man  aged  sixty-four  years,  who 
suffered  from  intermittent  haematuria  for  ten  years.  There  w^ere  no 
other  symptoms.  Finally  repeated  sounding  caused  cystitis.  After 
a  few  attacks  of  severe  pain  he  passed  some  fragments  of  stone, 
Following  this,  the  urine  became  normal  and  he  regained  his  health. 
Shortly  cystitis  again  developed,  and  was  characterized  by  tenesmus 
and  pain  referred  to  the  end  of  the  penis.  The  patient  suddenly 
became  collapsed,  with  distended  abdomen  and  all  the  signs  of  peri- 
tonitis.   Autopsy  showed  that  a  diverticulum  containing  a  number  of 

29 


450  GEIS'ITO-UEINAEY   DISEASES   AND    SYPHILIS. 

concretions  had  ruptured,  allowing  the  urine  to  escape  into  the  general 
peritoneal  cavity. 

From  constant  engorgement  the  prostate  slowly  enlarges,  and,  by 
obstructing  the  outflow  of  the  urine,  favors  retention,  with  reflux  of 
septic  fluid  into  the  ureters  and  kidney  pelves,  and  consequent  pyelo- 
nephritis.    Hence  the  prognosis  of  untreated  calculus  is  grave. 

Morris  states  that  if,  after  years  of  comfortable  life  with  a  stone  in 
the  bladder,  painful  symptoms  should  necessitate  an  operation,  the 
patient  is  only  too  likely  to  succumb  from  suppression  of  urine  or 
from  suppurative  pyelonephritis,  because  the  ureters  are  usually 
greatly  dilated  and  the  renal  tissue  atrophied.  He  also  calls  atten- 
tion to  the  fact  that  spontaneous  fragmentation  of  stone  may  occur, 
leading  to  complete  disintegration  and  expulsion  of  the  fragments. 

Frojjhylaxis. — The  presence  of  gravel  in  the  urine,  or  other  evi- 
dence of  supersaturation  with  solids,  such,  for  instance,  as  heavy  de- 
posits, should  lead  to  such  hygienic  and  dietetic  regulations  as  would 
naturally  tend  to  lessen  the  specific  gravity  of  the  urine  passed.  Of 
prime  importance  is  the  careful  regulation  of  the  stomach,  since 
when  the  functions  of  this  organ  are  interfered  with,  even  to  a  slight 
degree,  the  quantity  of  uric  acid  in  the  urine  is  markedly  increased. 

Systematic  exercise  should  be  prescribed,  and  the  bowels  kept 
fairly  soluble,  preferably  by  sahnes  administered  in  the  morning  on 
rising  and  at  night  just  before  retiring.  This  latter  time  is  particu- 
larly one  of  choice  in  the  case  of  an  alkaline  mineral  water,  because 
the  urine  naturahy  becomes  most  acid  during  the  smaU  hours  of  the 
morning.  The  liver  should  be  occasionally  stimulated  to  full  activity 
by  small  doses  of  calomel  frequently  repeated,  or  by  a  blue  pill. 
Supersaturation  of  the  urine  is  avoided  by  diluting  it  with  water  or 
bland  hquids.  These  must  not  be  taken  in  sufficient  quantity  to 
cause  indigestion.  Since  salt  renders  uric  acid  more  soluble,  it  is 
weh  to  use  this  liberally  with  food. 

When  there  is  gravel-formation,  or  quick  deposit  of  uric  acid  after 
passing  water,  direct  solvents  should  be  employed  intermittently.  Of 
these  saMcyhc  acid  or  potassium  salts  are  among  the  most  useful. 
Piperazin  is  also  of  service  in  preventing  stone,  since  it  has  the 
power  of  dissolving  uric  acid,  and  also  of  making  oxidation  more 
complete.  It  is  best  given  in  large  quantities  of  water :  fifteen  grains 
may  be  dissolved  in  a  pint,  this  whole  portion  being  taken  in  divided 
doses  during  the  day.  It  should  not  be  administered  in  pill  form. 
It  has  been  stated  that  this  drug  will  not  only  prevent  formation  of 
uric  acid  stones,  but  will  even  dissolve  those  already  formed,  and 
also  the  "colloid  matter  which  is  always  found  as  the  medium  in  which 


CALCULUS  OF  THE  BLADDEK.  45I 

the  formation  of  the  calculus  takes  place.  Clinical  evidence  of  such 
action  is  wanting. 

Alkaline  urine  will  also  slowly  dissolve  pure  uric  acid :  hence 
when  for  any  reason  operation  is  inadvisable,  it  would  seem  worth 
while  to  render  the  urine  alkaline  by  the  administration  of  full  doses 
of  potassium  citrate,  this  drug  being  eliminated  as  the  carbonate. 
When  the  urine  shows  excess  of  phosphates,  a  tonic  treatment, 
together  with  the  use  of  nitrohydrochloric  acid,  is  indicated. 

The  formation  of  stone  can  sometimes  be  prevented  by  careful 
attention  to  the  bladder.  Remedies  designed  to  render  the  urine 
bland  and  unirritating  act  locally,  since  they  lessen  the  bladder-irri- 
tation, and  thereby  the  secretion  of  albuminoid  or  colloid  material, 
without  which  calculi  will  not  form.  When  there  is  obstruction  to 
the  free  evacuation  of  the  urine,  regular  drainage  of  the  bladder  by 
means  of  a  catheter  is  serviceable ;  and  when  there  is  cystitis,  the 
administration  by  the  mouth  of  substances  which  are  antiseptic  when 
eliminated  by  the  urine,  and  direct  irrigation  of  the  bladder,  should 
be  practised.  The  antiseptic  drugs  administered  by  the  mouth  have 
already  been  considered,  as  have  also  the  local  washings  appropriate 
in  cystitis. 

Treatment. — Stone  having  once  formed  and  having  been  detected 
by  direct  examination,  it  remains  to  advise  treatment.  At  one  time 
attempts  at  removing  calculi  by  the  injection  of  solvent  lotions  into 
the  bladder,  or  by  the  administration  of  medicines  which  when  elim- 
inated with  the  urine  were  supposed  to  dissolve  the  calculi,  were 
popular.  These  methods  are,  however,  so  utterly  wanting  in  evidence 
as  to  their  efficiency  that  they  are  not  worth  considering. 

The  two  received  methods  of  treatment  are  (1)  litholapaxy, — 
crushing  and  evacuating  ;  (2)  cystotomy, — removing  the  stone  through 
either  a  perineal  or  a  suprapubic  incision.  Litholapaxy  is  in  both 
adults  and  children  the  method  of  choice. 

Preliminary  Preparation. — Whether  the  operation  be  crushing  or 
cutting,  the  preliminary  preparation  of  the  patient  is  about  the  same. 
Except  in  old  feeble  prostatics,  rest  in  bed  is  desirable  for  two  or 
three  days.  This  has  a  markedly  beneficial  effect  upon  the  cystitis, 
since  the  calculus  is  kept  quiet  and  does  not  mechanically  irritate  the 
bladder.  The  bowels  should  be  regularly  opened  by  salines  and  ene- 
mata,  and  the  urine  rendered  bland  by  milk  diet  and  diluents,  and 
slightly  antiseptic  by  salol  and  boric  acid.  Hsematuria  will  usually 
cease  promptly  as  the  result  of  rest.  Cystitis  should  be  modified  by 
irrigations  or  instillations.  When  the  circulation  is  feeble,  tonics  and 
strychnine  are  indicated. 


452 


GENITO-UKINAKY  DISEASES   AND  SYPHILIS. 


On  the  night  preceding  operation  the  patient  should  be  given  a 
laxative  and  a  general  hot  bath,  and  should  have  the  pubes  and  peri- 
neum shaved,  and  the  v^^hole  operative  area,  including  the  penis  and 
glans,  treated  as  is  customary  in  preparation  for  formal  operations,— 
i.e.^  cleansed  with  antiseptics  and  covered  in  by  an  antiseptic  gauze 
dressing. 

An  enema  should  be  given  not  less  than  four  hours  before  opera- 
tion. Immediately  before  operation  the  dressing  is  removed,  and  the 
whole  region  again  cleansed  by  green  soap,  benzin,  alcohol,  and  bi- 
chloride. This  preparation  applies  to  litholapaxy  because  that  oper- 
ation may  have  to  be  supplemented  by  lithotomy, — from  jamming  or 
breaking  of  the  lithotrite,  for  instance,  or  because  of  an  unexpectedly 
large  stone. 

LITHOLAPAXY. 
To  perform  the  operation  an  instrument  for  crushing  the  stone 
and  one  for  evacuating  the  fragments  after  crushing  are  needed.     The 
operation  in  its  entirety  was  first  practised  by  Bigelow  in  1878,  and 
has  since  then  largely  supplanted  all  cutting  operations. 

Fig.  138. 


Bigelow 's  lithotrite. 

The  crushing  instrument,  or  lithotrite,  devised  and  since  perfected 
by  Bigelow  (Fig.  138),  is  the  one  commonly  employed,  and  perhaps  is 
more  satisfactory  than  any  of  the  many  modifications  since  suggested, 

(Fig,  139.) 

Fig.  139. 


Weiss's  lithotrite. 


The  instrument  as  now  made  contains  a  male  and  a  female 
blade,  so  arranged  that  they  can  be  seprrated  or  approximated  by  a 
sliding  motion.     As  soon  as  the  calculus  is  grasped  the  blades  are 


CALCULUS  OP  THE  BLADDEK. 


453 


locked  by  a  turn  of  the  collar  of  the  handle ;  this  turn  at  the  same 
time  brings  a  powerful  screw  in  proper  relation  with  a  set  of  threads, 
so  that  on  turning  the  knob  of  the  extremity  of  the  handle  the  male 
blade  is  forced  downward  and  thus  crushes  the  stone.  Especial  at- 
tention is  devoted  to  the  construction  of  the  jaws  and  teeth ;  these 
are  so  made  that  clogging  by  the  lodgement  of  masses  of  crushed 
calculi  is  impossible.  Instruments  made  with  wide  fenestrae  passing 
completely  through  the  female  blade  are  liable  to  have  fragments  jam 
so  firmly  that  to  remove  the  instrument  without  laceration  of  the 
urethra  suprapubic  cystotomy  may  be  required.  The  male  blade — 
i.e.,  the  sliding  one — has  blunt,  pyramidal  projections  on  the  jaw,  so 
that  the  cusps  alone  catch  the  calculus.  As  the  latter  is  broken  the 
fragments  are  shed  to  the  sides,  instead  of  being  jammed  against  the 
female  blade.  The  latter  is  fenestrated  only  at  its  base,  to  receive 
a  spur  on  the  base  of  the  male  blade,  thus  preventing  the  clogging  of 
its  heel  by  small  fragments.     (Fig.  140.)     The  tip  of  the  female  blade 

Fig.  140. 


Jaws  of  Bigelow's  lithotrite. 


is  slightly  prolonged  and  curved  back,  thus  allowing  it  to  slide  readily 
into  the  urethra,  and  also  lessening  the  danger  of  penetrating  the 
vesical  mucosa  as  the  blades  are  brought  together. 

The  advantages  of  this  instrument  are  that  it  is  powerful,  does 
not  jam,  is  simple  in  construction,  and  enables  the  operator  to  search 
for  the  calculus,  grasp  it,  and  crush  it  without  taking  his  hands  from 
the  handle  and  without  having  to  pause  to  separate  the  blades  again 
by  unscrewing. 

The  evacuating  instruments  required  in  the  operation  of  litho- 
lapaxy  are  full-sized  catheters  of  varying  sizes,  straight,  or  with  a  very 
slight  curve  at  the  end,  provided  with  eyes  fully  as  large  as  the  calibre 
of  the  tube,  and  an  aspirating  apparatus,  which  consists  of  a  thick 
rubber  bulb  with  a  wide-mouthed  glass  receiver  attached  below  and 
an  opening  and  stopcock  above,  so  that  it  can  be  completely  filled 
with  water.     (Fig.  141.)     It  has  a  double  stopcock  on  the  side,  the 


454 


GENITO-UKINARY   DISEASES   AND  SYPHILIS. 


latter  fitting  to  the  catheters  externally,  and  internally  connecting 
with  a  fenestrated  tube,  which  penetrates  one  or  more  inches  into 
the  bulb.    The  aggregate  emptying  power  of  these  fenestrse  is  greater 


Fig.  141. 


Bigelow's  evacuator  and  tubes,  with  metal  cup  and  soft  rubber  tube  for  filling. 

than  the  open  end  of  the  tube,  so  that  in  forcing  water  into  the  blad- 
der it  rushes  in  through  these  small  lateral  holes  with  greater  velocity 
than  through  the  large  opening  at  the  end.  Thus  there  is  little  dan- 
ger that  fragments  will  be  drawn  up  into  this  tube  from  the  receiver 
and  driven  back  against  the  walls  of  the  bladder. 

Operation. — The  anaesthesia  should  be  profound  so  as  to  render 
the  bladder- wall  passive  and  prevent  reflex  movements  when  the 
instrument  is  inserted.  The  urine  is  drawn,  and  the  bladder  is  irri- 
gated with  an  antiseptic,  either  silver  1  to  5000  or  a  sterile  satu- 
rated solution  of  boric  acid ;  six  ounces  of  boric  acid  solution  are 
then  injected,  preferably  through  the  evacuator  which  the  surgeon 
intends  to  use,  as  it  is  then  certain  that  the  urethral  calibre  will  admit 
it.  The  patient  is  placed  upon  his  back,  the  shoulders  are  raised,  and 
the  thighs  well  separated  and  slightly  flexed.  The  lithotrite  is  intro- 
duced exactly  as  a  sound  is  passed,  the  surgeon  standing  at  the  patient's 
left ;  spasm  of  the  compressor  urethrae  muscle  is  overcome  by  the  weight 
of  the  instrument.  It  must  be  remembered  that  the  weight  of  the  litho- 
trite and  its  long  shaft  place  a  powerful  lever  in  the  hands  of  the  surgeon, 
which,  if  used  improperly,  may  cause  urethral  rupture.    When  the  beak 


Fig.  142. 


Opening  and  closing  the  blades  of  the  instrument  while  seai-ching  for  and 
grasping  the  calculus. 


Fig.  143. 


Crushing  a  small,  soft  calculus. 


Fig.  144. 


d     .t  / 

Crushing  a  large,  hard  stone. 


Fig.  145. 


Kvacuating-  fragments  after  the  calculus  has  been  crushed. 


CALCULUS  or  THE  BLADDER  455 

of  the  instrument  enters  the  bladder,  the  handle  will  lie  between  the 
thighs.  The  surgeon  then  passes  to  the  patient's  right.  The  beak 
should  be  gently  pushed  onward  until  it  touches  the  posterior  wall 
of  the  bladder,  when  the  blades  are  separated  until  the  male  blade 
touches  the  neck  of  the  bladder ;  they  are  then  closed  rapidly.  If 
the  calculus  is  caught,  it  should  be  fixed  by  a  turn  of  the  collar  and 
then  crushed  by  turning  the  screw-handle.  If  the  calculus  is  not 
caught  in  the  first  manoeuvre,  the  beak  of  the  instrument  should 
be  gently  turned  from  one  side  to  the  other,  alternately  opening  and 
closing  the  jaws.  If  it  still  eludes  the  grasp,  the  lithotrite  should  be 
turned  with  the  beak  directly  downward,  thus  exploring  the  region 
behind  the  prostate. 

Whenever  the  calculus  is  grasped  it  should  be  firmly  fixed  by  a 
half-turn  of  the  handle,  and  the  instrument  should  then  be  turned 
so  that  its  beak  points  upward,  and  be  withdrawn  so  that  the  stone 
will  be,  as  nearly  as  can  be  guessed,  in  the  centre  of  the  bladder. 
By  this  manipulation  the  operator  can  assure  himself  that  he  has  not 
grasped  a  portion  of  the  mucous  membrane,  and  can  proceed  to  crush 
the  stone  by  rapidly  screwing  down  the  handle.  These  manoeuvres 
are  repeated  until  the  stone  is  reduced  to  small  fragments.  Were 
the  operation  to  terminate  here,  as  was  at  one  time  advised,  it  would 
be  lithotrity,  the  older  method  being  to  allow  patients  to  evacuate  by 
natural  efforts  the  fragments  of  stone  thus  crushed.  This  is,  how- 
ever, highly  undesirable,  for  obvious  reasons. 

The  tightly  closed  lithotrite  having  been  withdrawn,  an  evacu- 
ating catheter  of  as  large  a  size  as  can  be  introduced  through  the 
urethra  is  passed.  The  extremity  of  this  instrument  being  kept  well 
against  the  urethral  roof,  when  it  reaches  the  membranous  portion 
of  this  canal  its  outer  extremity  is  carried  downward,  pressure  being 
exerted  at  the  same  time  at  the  root  of  the  penis  by  the  index  and 
middle  finger  of  the  left  hand  placed  on  either  side  of  this  organ,  thus 
relaxing  the  suspensory  ligament  and  straightening  out  the  urethra. 
This  manoeuvre  is  especially  useful  when,  as  in  this  instance,  it  is 
necessary  to  pass  an  instrument  the  curve  of  which  is  less  than  the 
fixed  curve  of  the  urethra. 

The  evacuating  bulb,  filled  with  warm  boric  acid  solution  or 
sterile  water,  is  then  connected  with  the  catheter,  the  stopcocks 
between  the  two  are  turned  on,  the  bubbles  of  air  contained  in  the 
catheter  are  allowed  to  rise  to  the  top  of  the  bulb  and  are  squeezed 
out,  the  stopcock  there  being  turned  on  for  a  moment,  and  then, 
by  gentle  slow  pressure,  about  half  tlie  fluid  in  the  bulb  is  allowed 
to  pass  through  the  catheter  into  the  bladder.     After  waiting  a  few 


456  GENITO-UEINAEY   DISEASES   A'SB   SYPHILIS. 

seconds  for  the  fragments  to  settle  about  the  base  of  the  bladder, 
the  pressure  on  the  rubber  bulb  is  suddenly  relaxed,  and  thus  the 
fragments  are  sucked  up  into  the  glass  receiver.  This  process  of 
alternately  distending  the  bladder  and  sucking  out  the  fluid  is  con- 
tinued, the  catheter  being  carried  in  different  directions,  until  no  more 
fragments  escape.  This  may  be  determined  by  auscultation  over  the 
bladder  during  the  process  of  aspiration,  any  fragments  which  remain 
being  heard  to  click  against  the  evacuating  catheter.  The  catheter 
should  then  be  withdrawn,  the  stone-searcher  introduced,  and  careful 
search  made  for  any  remaining  calculus ;  none  being  found,  the  oper- 
ation is  completed. 

In  place  of  the  aspirating  instrument  used  by  Bigelow,  it  is 
worthy  of  note  that  if  the  fragment  is  thoroughly  pulverized  the 
natural  expulsive  force  of  the  bladder  is  sufficient  entirely  to  evacu- 
ate the  fragments.  This  may  be  accomplished  by  introducing  a  full- 
sized  catheter,  distending  the  bladder  by  a  gravity-bag  or  syringe, 
then  allowing  the  contents  to  flow  away  in  a  full-sized  stream.  It  is 
obvious,  however,  that  this  method  of  evacuation  is  not  so  sure  as 
that  provided  by  the  Bigelow  apparatus. 

The  only  serious  comphcation  Mable  to  occur  during  the  course  of 
litholapaxy  is  the  clogging  of  the  blades.  This  should  be  obviated 
by  rapping  them  sharply  and  quickly  together  several  times.  If  this 
manoeuvre  fails,  the  tip  of  the  instrument  should  be  brought  up 
against  the  pubis  and  suprapubic  cystotomy  performed.  In  case  the 
bladder  should  be  ruptured,  immediate  suprapubic  cystotomy  and 
drainage  would  be  indicated. 

The  further  treatment  is  so  directed  that  the  patient  is  kept  quiet 
in  bed  on  a  milk  chet  for  Ave  to  seven  days,  or  until  pus  and  blood 
disappear  from  the  urine.  During  this  time  salol  is  given  by  the 
mouth  and  the  bowels  are  kept  open  by  enemata.  For  the  first 
twenty-four  hours  after  operation  the  whole  abdomen  should  be 
covered  with  hot  antiseptic  compresses,  changed  every  two  hours. 

Guy  on  warmly  commends  the  retained  catheter  as  an  after-treat- 
ment of  litholapaxy,  keeping  it  in  place  for  twenty-four  hours.  Many 
of  his  cases  had  been  infected  for  a  long  time,  and  were  old  pros- 
tatics  with  phosphatic  calculi,  the  class  in  whom  vesical  operation  is 
likely  to  result  fatally.  His  results  were  most  favorable,  and  seemed 
to  indicate  that  the  retained  catheter  distinctly  lessens  mortality  in 
infected  prostatics  with  vesical  calculi. 

Chismore  describes  a  modification  of  the  Bigelow  operation  •em- 
ployed by  him  in  fifty-two  cases.  His  patients  were  all  old,  and 
many  of  them  were  prostatics.      He  had  no  deaths.      He  believes 


CALCULUS  OF  THE  BLADDER.  457 

i 

that  his  method  is  particularly  applicable  to  cases  of  senile  atrophy 
with  pouched  or  irregular  bladder.  These  conditions,  together  with 
the  consequent  alterations  of  the  vesical  orifice  of  the  urethra,  make 
it  impossible  to  command  considerable  portions  of  the  cavity  of  the 
bladder  with  the  lithotrite,  or  indeed  with  any  instrument  introduced 
into  the  urethra  or  through  a  perineal  incision,  besides  favoring  the 
escape  and  retention  of  fragments  of  calculi  during  litholapaxy. 

Chismore  substitutes  local  for  general  anaesthesia,  and  conducts 
his  crushings  in  a  series  of  short  office-sittings.  He  empties  the 
bladder,  injects  one  or  two  fluidounces  of  a  four  per  cent,  solution 
of  cocaine  hydrochlorate,  gently  inserts  the  lithotrite,  and  seizes  and 
crushes  the  stone.  If  a  large  fragment  apparently  disappears,  he 
makes  no  prolonged  attempt  to  find  it  at  that  sitting.  He  crushes 
as  long  as  fragments  are  readily  found,  washes  out  the  pieces,  and 
stops  the  moment  spasm  of  the  bladder,  unusual  distress,  or  symp- 
toms of  exhaustion  occur.  He  does  not  hesitate  to  leave  some  pieces 
after  crushing,  but  removes  them  after  the  reaction  due  to  operation 
has  subsided,  and  as  soon  as  they  can  b  ■  felt  with  a  searcher,  usually 
within  a  week.  He  repeats  his  partial  operations  and  evacuations 
until  the  bladder  is  clear.  As  these  patients  usually  have  strictures, 
or  at  least  a  narrowed  urethra,  a  period  of  preliminary  dilatation  is 
often  necessary. 

The  male  blade  of  his  lithotrite  is  hollow,  and  is  attached  to  an 
evacuator  of  simple  and  ingenious  construction.  As  the  stone  is 
crushed  it  is  evacuated  through  the  male  blade.  This  avoids  repeated 
passing  of  instruments,  and  is  also  a  valuable  means  of  drawing  into 
the  grip  of  the  lithotrite  calculi  which  otherwise  could  not  be  reached ; 
for  when  the  instrument  is  opened,  if  the  bulb  of  the  evacuator  is 
compressed  and  then  suddenly  released,  fine  fragments  will  be  drawn 
through  the  canula  of  the  male  blade  and  into  the  receptacle  placed 
externally,  while  fragments  too  large  to  pass  will  be  sucked  exactly 
into  the  grip  of  the  instrument.  When  no  more  pieces  of  stone  are 
readily  found,  Chismore  washes  out  the  bladder  with  warm  boric  acid 
solution.  This  operation  is  conducted  in  his  office,  the  patient  paying 
visits  as  often  as  is  required.  Following  operation  there  is  usually 
an  immediate  sense  of  relief;  the  reaction  is  slight.  The  patient's 
sensations  will  prove  a  valuable  guide  as  to  the  presence  or  absence 
of  further  fragments.  When  frequency,  tenesmus,  purulent  urine, 
and  a  sensation  of  stone  occur,  the  searcher  is  used,  the  presence 
of  a  stone  determined,  and  the  operation  repeated. 

Perineal  Litholapaxy. — This  operation,  which  was  originally 
described  by  Keith  in  1892,  has  not  met  with  the  success  which  its 


458  GEFITO-UEINAKY    DISEASES   AND    SYPHILIS. 

advan+ages  should  justify.  Many  authors  indicate  the  performance 
of  the  perineal  operation  under  some  or  all  of  the  following  con- 
ditions :  (1)  A  large  stone  necessitating  the  use  of  a  lithotrite  which 
will  not  pass  easily  by  the  natural  route.  (2)  A  very  hard  stone 
necessitating  the  passage  of  a  similar  instrument.  (3)  Stricture  in 
conjunction  with  a  large  or  hard  stone  or  perhaps  of  any  stone.  (4) 
A  difficult  or  narrow  urethra.  (5)  Imperfect  equipment.  (6)  Cases 
in  which  litholapaxy  has  been  commenced  in  the  ordinary  way,  but 
cannot  be  completed  satisfactorily  owing  to  swelling  of  the  urethra  and 
deposit  of  debris.  The  operation  differs  somewhat  from  that  of 
lithotomy.  A  curved  staff  with  a  median  groove  is  introduced  into 
the  bladder.  The  scrotum  is  allowed  to  assume  its  natural  position. 
A  very  small  incision  is  now  made  with  the  point  of  a  tenotomy  knife, 
in  children  about  one  inch  in  front  of  the  anus  through  the  median 
raphe,  and  the  urethra  incised  for  one-eighth  of  an  inch.  The  point 
of  an  ordinary  director  is  inserted  through  the  wound  and  passed  into 
tho  bladder  through  the  prostatic  urethra,  which  is  then  dilated  up  to 
the  required  size.  The  evacuating  catheter  is  now  passed,  the  bladder 
injected,  and  the  lithotrite  follows  without  difficulty.  The  operation 
is  completed  in  the  same  way  as  in  ordinary  litholapaxy,  and,  as  a 
rule,  there  is  no  difficulty  in  retaining  fluid  in  the  bladder.  In  order 
to  avoid  a  valvular  aperture,  it  is  most  important  that  the  skin  should 
not  be  displaced  while  making  the  incision.  This  method  is  not  in- 
tended to  replace  lithotomy,  which  will  remain  the  operation  of  choice 
when  cutting  must  be  done. 

Reginald  Harrison  is  perhaps  the  strongest  advocate  of  this  pro- 
cedure. He  thus  sums  up  the  chief  points  in  favor  of  perineal  litho- 
lapaxy: "(1)  It  enables  the  operator  to  crush  and  evacuate  large 
stones  in  a  short  space  of  time.  (2)  It  is  attended  with  a  very  small 
risk  to  life  as  compared  with  other  operations  where  any  cutting  is 
done,  such  as  lateral  or  suprapubic  lithotomy,  and  is  well  adapted 
to  old  and  feeble  subjects.  Swinford  Edwards  has  shown  that  the 
latter  operation  for  large  stones  has  a  mortality  somewhat  about 
fifty  per  cent.  (3)  It  permits  the  operator  to  wash  out  the  bladder 
and  any  pouches  connected  with  it  more  effectually  than  by  the 
urethra,  as  the  route  is  shorter  and  the  evacuating  catheters  em- 
ployed of  much  larger  calibre.  (4)  The  surgeon  can  usually  ascer- 
tain, either  by  exploration  with  the  finger  or  by  the  introduction 
of  forceps  into  the  bladder,  that  the  viscus  is  cleared  of  all  debris. 
(5)  It  enables  the  surgeon  to  deal  with  certain  forms  of  prostatic  out- 
growth and  obstruction  complicated  with  atony  of  the  bladder  in 
such  a  way  as  to  secure  not  only  the  removal  of  the  stone  but  the 


CALCULUS  OF  THE  BLADDER.  459 

restoration  of  the  function  of  micturition.  (6)  By  the  subsequent  in- 
troduction and  temporary  retention  of  a  soft  rubber  drainage-tube 
states  of  cystitis  due  to  the  retention  of  urine  in  pouches  and  depres- 
sions in  the  bladder-wall  are  either  entirely  cured  or  are  perma- 
nently improved.  To  lock  up  unhealthy  ammoniacal  urine  in  a 
bladder  that  cannot  properly  empty  itself  after  a  lithotrity  is  to  court 
the  formation  or  recurrence  of  a  phosphatic  stone.  Hence  it  is  well 
suited  to  some  cases  of  recurrent  calculus, 

"  It  is  well  adapted  for  some  cases  of  stone  in  the  bladder  compli- 
cated with  stricture  in  the  deep  urethra,  as  it  enables  the  surgeon  to 
deal  with  both  at  the  same  time.  Nor  does  it  expose  the  patient  to 
the  risk  which  may  be  attendant  where  lithotrity  is  performed  with  a 
weakened  or  permanently  damaged  urethra." 

Harrison  demonstrated  that  crushing  forceps  shaped  somewhat 
like  the  blades  of  a  lithotrite,  and  not  exceeding  in  circumference  that 
of  the  ordinary  index  finger,  are  sufficiently  powerful  to  pulverize  any 
stone  that  can  be  thoroughly  seized.  The  fragments  may  be  subse- 
quently withdrawn  by  means  of  evacuating  catheters  passed  through 
the  wound,  or  even  by  forceps.  If  care  is  taken  to  make  the  perineal 
opening  of  a  size  corresponding  to  that  of  the  evacuating  catheters, 
which  should  be  as  large  as  an  ordinary  index  finger,  the  bladder  is 
readily  kept  distended  during  the  necessary  nianipulations. 

The  opening  is  made  into  the  membranous  urethra  at  the  apex 
of  the  prostate  on  a  grooved  staff  passed  along  the  urethra.  Through 
this  opening  is  first  passed  the  Wheelhouse  tapering  gorget,  and 
guided  by  this  instrument  the  index  finger  is  introduced  into  the 
bladder. 

Litholapaxy  in  Children  (infancy  to  puberty). — There  has  long 
been  a  popular  belief  that  in  children  lithotomy  is  a  safer  operation 
than  litholapaxy.  Recent  statistics  have  established  beyond  cavil  the 
greater  safety  of  the  latter  operation. 

Of  1213  cases  performed  by  eleven  operators  the  mortality  was 
2.22  per  cent. ;  perineal  lithotomy  gives  a  mortality  twice  as  great  as 
this ;  suprapubic  lithotomy  one  more  than  five  times  as  great.  The 
combined  statistics  of  Cabot  and  Barling  are  still  more  favorable  to 
the  crushing  operation:  perineal  lithotomy,  602  cases,  19  deaths, — 
a  percentage  of  3.1 ;  suprapubic  lithotomy,  637  cases,  84  deaths, — 
a  mortality  of  13.1  per  cent. ;  litholapaxy,  284  cases,  5  deaths, — a 
mortality  of  1.7  per  cent. 

No  age  is  exempt  from  calculus,  since  it  has  been  found  in  the 
festal  bladder.  About  half  of  all  cases  of  vesical  stone  are  observed, 
in  children :  hence  in  them  operation  for  its  removal  is  frequently  re- 


460  GENITO-UEINARY   DISEASES  AND   SYPHILIS. 

quired.  Keegan  states  ttiat  the  urethra  of  a  child  from  three  to  six 
years  of  age  will  usually  accommodate  a  No.  6  to  No.  8  English 
lithotrite,  while  a  No.  12  to  No.  14  can  be  passed  into  the  urethra 
of  a  child  of  eight  to  ten  years. 

Otis  has  shown  that  in  children  as  in  adults  the  small  diameter 
of  the  uretlira  may  be  greatly  increased  with  entire  safety.  He  states 
that  the  proportionate  relation  between  the  circumference  of  the 
urethra  and  that  of  the  penis  which  he  believes  to  exist  in  adults 
holds  good  in  children.  Thus,  with  a  penile  circumference  of  one 
and  a  half  inches,  as  in  a  child  from  two  to  three  years  of  age,  the 
size  of  the  urethra  would  not  be  less  than  fifteen  millimetres.  For 
every  quarter  of  an  inch  added  to  the  penile  circumference  two 
millimetres  may  be  added  to  the  urethral  calibre.  It  should  be  re- 
membered that  this  indicates  rather  the  distensibility  than  the  actual 
calibre  of  the  canal. 

Recurrence  of  stone  may  be  observed  after  any  operation.  Kee- 
gan states  that  after  an  extended  experience  he  is  convinced  that  this 
recurrence  in  male  children  does  not  follow  litholapaxy  oftener  than 
it  follows  lithotomy. 

There  are  certain  objections  to  the  operation  of  lithotomy  which, 
even  were  its  mortality  as  low  as  that  of  litholapaxy,  should  have  due 
weight  in  deciding  for  one  operation  or  the  other.  Thus,  the  space  in 
which  manipulations  must  be  conducted  is  extremely  small,  often  pre- 
venting the  introduction  of  a  fmger  along  the  staff.  Of  course  this 
can  be  obviated  by  making  no  digital  exploration  of  the  bladder,  the 
small  forceps  being  passed  in  directly  and  the  stone  thus  removed ; 
but  in  this  case  the  surgeon  cannot  be  sure  that  the  bladder  is  en- 
tirely empty.  The  high  position  of  the  bladder  in  children,  the  deli- 
cacy and  mobility  of  the  deep  urethra,  the  danger  of  wounding  the 
bulb  in  making  an  incision  which  is  sufficiently  large,  and  the  possi- 
bility of  the  operation  being  followed  by  sterility  are  all  factors  which 
should  be  considered  in  cutting  for  stone  in  children. 

Cabot  says  that  his  experience  has  proved  that  the  urethra  and 
bladder  of  children  are  extremely  tolerant  of  instrumentation :  hence 
he  advises  litholapaxy  for  small  stones  or  those  of  moderate  size  (from 
three-fifths  to  four-fifths  of  an  inch  in  diameter),  and  for  larger  stones 
perineal  lithotomy,  unless  they  are  of  unusual  size  (from  one  to  one 
and  a  half  inches  in  diameter),  when  suprapubic  cystotomy  is  indi- 
cated. It  is  fairly  easy  to  determine  the  approximate  size  of  calculi 
in  children  by  bimanual  palpation.  Guided  by  this,  the  appropriate 
method  is  selected. 

After   due  consideration  of  the  opinions  of  others  and  an   ex- 


CALCULUS  OF  THE  BLADDEE.  461 

tended  personal  experience,  we  believe  the  following  conclusions  to 
be  justifiable. 

In  every  case  of  calculus  in  male  children  litholapaxy,  on  account 
of  ease  of  performance,  low  mortality,  speedy  recovery,  and  absence 
of  danger  of  emasculation,  should  be  the  operation  of  predilection, 
division  of  the  meatus  being  freely  resorted  to  if  that  portion  of  the 
urethra  offers  an  obstacle  to  the  introduction  of  instruments. 

The  lithotrite  and  evacuating-tube  should  be  of  such  size  that  they 
can  be  inserted  into  the  bladder  without  much  effort  or  over-distention, 
and  great  gentleness  should  be  observed  in  passing  these  instruments. 
Keegan  says,  "  When  I  advocate  litholapaxy  as  being  the  best  opera- 
tion, in  my  opinion,  for  the  great  majority  of  stones  occurring  in  male 
children  and  boys,  I  do  so  with  a  very  important  reservation, — viz., 
that  no  one  should  attempt  to  perform  it  in  boys  until  he  has  first 
gained  some  practical  experience  of  it  in  adult  males.  The  surgeon 
who  meets  with  cases  of  stone  only  at  rare  intervals  during  his  career 
will  be  acting  more  wisely  if  he  adheres  to  lateral  lithotomy  or  supra- 
pubic cystotomy.  It  is  his  misfortune  and  not  his  fault  that  he  has 
not  been  afforded  many  opportunities  of  gaining  a  practical  familiarity 
with  the  use  of  the  lithotrite.  Should  he  aspire  to  performing  this 
operation  widely  and  successfully  in  male  children  and  boys,  he  must 
provide  himself  with  a  large  assortment  of  fully  fenestrated  lithotrites 
of  small  size,  made  from  the  best  steel  which  money  can  purchase, 
by  thoroughly  reliable  workmen.  His  set  of  lithotrites,  all  fully  fenes- 
trated, should  range  from  No.  4  or  5  at  the  bend  of  the  blades  to 
No.  10  at  the  end  of  the  blades  (English  scale),  and  his  evacuating 
catheters  or  canulse  should  be  fitted  with  serviceable  stylets." 

The  instrument  should  be  withdrawn  and  reintroduced  as  seldom 
as  possible.  If,  however,  a  lithotrite  which  fits  the  urethra  tightly  has 
been  used,  it  is  well  to  change  this  for  one  of  smaller  size  before  pul- 
verization of  the  fragments,  since  the  entrance  of  the  calculus  sand 
into  the  urethra,  by  making  the  shaft  of  the  instrument  rough  and  by 
becoming  deposited  on  the  mucous  membrane,  may  render  the  with- 
drawal of  the  full-sized  instrument  exceedingly  difficult.  In  seeking 
for  or  attempting  to  seize  the  stone,  care  should  be  taken  to  avoid  such 
wide  separation  of  the  blades  as  will  bring  the  male  blade  in  frequent 
contact  with  the  vesical  neck.  The  crushing  should  invariably  be 
done  only  after  rotating  the  blades  into  the  centre  of  the  bladder. 
Every  particle  of  the  calculus  should  be  evacuated.  Copious  irri- 
gation of  the  anterior  urethra  through  a  soft  catheter  carried  to  the 
compressor  urethrae  muscle  aids  in  freeing  it  from  fine  solid  particles 
which  may  be  lodged  on  its  surface. 


462  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

Rest  in  bed,  milk  diet,  and  sterilization  of  the  urine  by  boric  acid 
or  salol  given  internally,  both  before  and  after  the  operation,  are  valu- 
able adjuvants.  During  the  operation  every  antiseptic  precaution 
should  be  observed.  Southam  very  properly  emphasizes  the  impor- 
tance (a)  of  this  preliminary  sterilization  of  the  urine  by  the  adminis- 
tration of  salol  and  boric  acid,  and  if  need  be  by  irrigation  of  the  blad- 
der, and  (6)  of  the  avoidance  of  shock  by  thorough  protection  of  the 
patient  against  surface  chilling. 

The  exceptional  cases  of  calculi  which  are  both  large  and  hard 
may  be  best  treated  by  suprapubic  lithotomy,  but  neither  unusual  size 
nor  a  moderate  degree  of  density  should  of  itself  be  thought  positively 
to  contra-indicate  litholapaxy. 

Perineal  lithotomy  has  now  a  very  limited  field,  and  should  be 
employed  chiefly  in  those  cases  in  which  the  stone  is  thought  to  be  of 
small  or  medium  size,  and  in  which  no  lithotrite,  however  small,  can 
be  introduced  with  safety. 

CoNTRA-iNDiGATioNs  TO  LITHOLAPAXY  are — 1.  Tight  fibrous  stricture 
of  the  deep  urethra.  This  contra-indication  is  not  absolute,  since 
the  stricture  may  be  divided  by  external  incision  and  the  stone  then 
crushed  and  evacuated.  Median  perineal  litholapaxy  or  lithotomy 
is  to  be  preferred.  2.  Severe  chronic  cystitis,  for  the  cure  of  which 
permanent  drainage,  supplemented  by  irrigations,  is  indicated.  3. 
Organic  visceral  lesions  which  make  the  prolonged  administration 
of  an  ansesthetic  especially  dangerous,  as  haemoptysis,  atheroma,  or  a 
history  of  apoplectic  attacks.  Under  such  circumstances  Chismore's 
operation  or  lithotomy  is  indicated.  4.  A  nucleus  that  cannot  be 
comminuted  or  removed  through  the  evacuating-tubes,  as  a  pipe- 
stem  or  a  lamp-wick.  5.  Sacculation  or  encysting  of  the  stone. 
Even  though  the  calculus  can  be  reached  by  the  hthotrite,  attempts 
to  seize  and  crush  it  are  dangerous,  since  the  vesical  walls  sur- 
rounding it  are  thin  and  extremely  vulnerable.  The  suprapubic 
operation  is  indicated  in  these  cases.  6.  Large  size  and  unusual 
hardness.  (Figs.  152,  153.)  A  very  few  stones  come  in  this  category. 
Small  hard  stones  should  be  taken  out  by  perineal  lithotomy.  Ex- 
ceptional hardness,  combined  with  great  size,  is  the  only  clear  indi- 
cation for  suprapubic  lithotomy  in  adults  before  middle  age,  except 
the  presence  of  stone  in  diverticula,  or  its  association  with  tumor 
or  other  conditions  requiring  for  their  treatment  the  suprapubic 
incision. 

The  most  recent  statistics  of  operation  performed  upon  calculus 
patients  ranging  from  puberty  to  middle  age  are  as  follows :  perineal 
lithotomy,  226  cases,  22  deaths,  9.7  per  cent.  ;  suprapubic  lithotomy, 


CALCULUS  OF  THE  BLADDER.  463 

159  cases,  18  deaths,  11.3  per  cent. ;  litholapaxy,  485  cases,  22  deaths, 
4.5  per  cent.  It  is  clear  from  these  figures  that  Utholopaxy  is  the  opera- 
tion of  choice.     Exceptionally  it  may  be  undesirable  or  impossible. 

The  superior  value  of  litholapaxy  in  old  age,  as  shown  by  statistical 
evidence,  is  even  more  striking  than  in  childhood  or  middle  age.  This 
is  as  follows  :  perineal  lithotomy,  69  cases,  13  deaths,  19  per  cent. ; 
suprapubic  lithotomy,  91  cases,  17  deaths,  18  per  cent. ;  litholapaxy, 
581  cases,  40  deaths,  7  per  cent.  In  old  age  the  special  contra-indi- 
cations  to  htholapaxy,  in  addition  to  those  mentioned  as  applying 
from  puberty  to  middle  age,  are — (1)  Enlargement  of  the  prostate  so 
pronounced  that  the  lithotrite  either  cannot  be  introduced,  or  if  suc- 
cessfully passed  cannot  reach  the  stone,  even  though  an  effort  be 
made  to  lift  this  from  the  post-prostatic  pouch  by  a  finger  in  the 
rectum.     (2)  Atony  of  the  bladder. 

Complications  of  Litholapaxy. — It  may  happen  that  the  surgeon, 
having  taken  it  for  granted,  because  of  the  history  of  the  patient, 
that  the  urethra  will  receive  his  instruments,  finds  some  obstruction 
which  prevents  them  from  passing.  Usually  this  is  because  of  a 
narrow  meatus.  In  that  case  it  is  at  once  obviated  by  meatotomy. 
It  may  be  from  an  anterior  stricture.  This  should  be  treated  by  in- 
ternal urethrotomy,  the  patient  then  wearing  a  continuous  catheter 
for  a  few  days  after  litholapaxy.  If  the  stricture  is  deep  and  dense, 
this  indicates  median  perineal  lithotomy  or  litholapaxy  together 
with  urethrotomy.  If  the  obstruction  is  in  the  prostate  and  cannot 
be  overcome  without  the  use  of  force,  the  crushing  operation  must  be 
abandoned. 

It  may  happen  that  though  the  urethra  receives  the  lithotrite,  the 
smallest  evacuating-tube  which  the  surgeon  has  fails  to  pass.  If  the 
stone  is  crushed  before  this  is  discovered,  it  constitutes  an  embarrassing 
complication,  since,  even  after  the  finest  practicable  fragmentation,  it 
is  comparatively  unsafe  to  allow  the  fragments  to  be  passed  through 
the  urethra.  It  is  with  the  idea  of  avoiding  this  complication  that  we 
have  advised  injection  of  the  bladder  through  the  evacuating-tube 
which  the  surgeon  intends  to  use.  He  will  then  discover  before 
having  crushed  the  stone  that  the  tube  cannot  be  passed,  and  can 
either  procure  a  smaller  tube  or  at  once  proceed  to  remove  the  stone 
by  the  appropriate  cutting  operation. 

If  the  stone  has  been  crushed  and  no  evacuator  can  be  intro- 
duced, but  a  staff  can  be  passed,  lateral  lithotomy  should  be  per- 
formed and  the  fragments  removed  by  the  scoop  and  irrigator. 

The  lithotrite  may  jam  with  the  blades  so  widely  open  that 
their  withdrawal  when  in  this  position  would  almost  certainly  entail 


464  GENITO-UEINARY   DISEASES   AND    SYPHILIS. 

laceration  of  the  urethra.  If  a  series  of  quick  jarring  closures  fail  to 
free  the  blades,  they  should  be  turned  forward  against  the  anterior 
surface  of  the  bladder  and  be  cut  down  upon  above  the  pubis ;  or 
they  may  be  reached  and  cleared  by  perineal  incision.  Bending  of 
the  blades  may  require  similar  operations.  Should  the  blades  break, 
the  shaft  should  be  removed,  if  possible,  without  the  exertion  of 
force ;  the  fragments  can  then  be  taken  out  by  a  median  perineal 
operation.  It  is  to  the  credit  of  the  instrument-makers  that  very 
few  hthotrites  have  been  bent  or  broken  in  crushing  stones. 

The  bladder  may  be  ruptured  during  preliminary  injection  or 
during  attempts  at  evacuation  of  the  stone  fragments.  Rupture  during 
injection  would  be  suggested  were  it  found  impossible  to  move  the 
blades  of  the  lithotrite  freely  in  the  bladder  for  want  of  room,  thus 
showing  it  to  be  partly  or  completely  empty.  If  this  accident  oc- 
curred during  the  use  of  the  evacuator,  unusually  free  bleeding  would 
be  noted,  and  the  liquid  injected  would  fail  to  return,  the  mucous 
membrane  being  constantly  sucked  into  the  eye  of  the  evacuating- 
tube,  in  whatever  position  this  might  be  placed. 

As  sequelae  of  litholapaxy  there  may  develop — (1)  Shock  or  col- 
lapse, resulting  fatally  in  a  few  hours.  (2)  Hemorrhage.  (3)  Sup- 
pression of  urine,  which  may  be  fatal  in  one  or  two  days.  This  is 
observed  in  old  persons  with  crippled  kidneys,  in  whom  the  slightest 
interference  is  liable  so  to  disturb  equilibrium  that  the  kidneys  be- 
come insufficient.  (4)  Urinary  fever.  This  may  be  transitory,  pass- 
ing off  in  from  twenty-four  to  forty-eight  hours,  or  may  develop  into  a 
true  septicgemia.  (5)  Ascending  pyelonephritis,  with  the  development 
of  surgical  kidney.  (6)  Prostatitis  and  epididymitis.  (7)  Pelvic  cellu- 
litis extending  from  a  pericystitis.  (8)  Phlebitis  involving  primarily 
the  prostatic  plexus,  sometimes  extending  to  the  whole  pelvic  venous 
system,  and  causing  extensive  thrombosis  with  oedema  of  the  legs,  or 
septic  embolism  and  death  from  pyaemia.  (9)  Peritonitis.  This  may 
be  caused  by  extension  of  inflammation  due  to  trauma  inflicted  on 
the  bladder-wall.  With  the  exception  of  uraemia  of  the  aged,  these 
complications  are  rare  if  proper  care  is  taken,  and  can  be  readily 
avoided. 

LITHOTOMY. 

Lithotomy,  as  this  word  is  used  in  surgery,  indicates  an  incision 
into  the  bladder  for  the  removal  of  stone.  The  bladder  may  be 
opened  through  the  perineum  by  lateral,  bilateral,  median,  or  medio- 
bilateral  incisions.  It  may  be  opened  through  the  abdominal  walls 
by  a  suprapubic  incision. 


CALCULUS  OF  THE  BLADDER. 


465 


Perineal  Lithotomy. — In  many  of  the  cases  not  suited  to  the 
operation  of  litholapaxy  the  stone  may  be  removed  through  an  incision 
which  involves  the  perineum  and  the  neck  of  the  bladder.  Some  few 
surgeons  still  hold  that  this  operation  is  the  one  of  choice  in  young 
children,  basing  this  opinion  upon  its  low  mortality.  Though  the 
mortality  is  undoubtedly  low  in  children,  that  of  litholapaxy  is  still 
lower,  as  has  been  abundantly  proved  by  modern  statistics. 

In  all  forms  of  perineal  lithotomy  the  following  anatomical  land- 
marks should  be  considered.  The  perineum  is  triangular  in  form, 
having  its  apex  at  the  symphysis  pubis,  and  .or  its  boundaries  the 
rami  of  the  ischia  and  pubis  laterally,  and  an  imaginary  line  passing 
through  the  centre  of  the  anus  and  connecting  the  tuberosities  of  the 
ischia.  The  perineal  centre  is  a  point  midway  between  the  centre  of 
the  anus  and  the  perineo-scrotal  junction  ;  it  marks  the  middle  of  the 
lower  edge  of  the  triangular  ligament.  Just  in  front  of  this  point  are 
the  bulb  of  the  penis  and  its  arteries.  The  raphe  extends  in  the  mid- 
perineal  line  from  the  anterior  edge  of  the  anus  up  over  the  scrotum. 
Beneath  it  there  are  no  arteries  of  importance. 

The  depth  of  tissue  between  the  skin  and  the  bladder  in  the  male 
adult  varies  from  two  and  a  half  to  three  inches  when  measured  near 
the  base  line  of  the  perineum,  and  about  an  inch  in  the  anterior 
portion. 

Fig.  146. 


Lithotomy  knile. 

Lateral  Lithotomy. — The   following  instruments  are  needed  for 
the   lateral   operation :  a   lithotomy   knife ;  this   is   a  scalpel  with  a 

Fig.  147. 


Grooved  lithotomy  staft. 


three-inch  blade  and  a  moderately  heavy  handle  (Fig.  146) ;  a  probe- 
pointed  bistoury,  for  enlarging  the  prostatic  incision,  should  this  be 

30 


466 


GENITO-URINAEY   DISEASES   AND   SYPHILIS. 


necessary ;  a  large  curved  lithotomy  staff  (Fig.  147),  grooved  on  the 
under  surface  or  on  the  side ;  the  lateral  groove  is  preferable,  be- 
cause it  is  more  easily  felt  by  the  fmger  in  the  wound  ;  the  groove 
should  be  deep  enough  to  prevent  the  knife  from  slipping  out  when 
once  engaged ;  straight  and  curved  lithotomy  forceps  (Fig.  148),  the 

Fig.  148. 


stone  forceps  (curved). 


straight  answering  for  most  purposes  except  when  the  calculus  is 
lodged  in  a  pouch  posterior  to  the  prostate,  when  the  curved  forceps 
will  be  required ;  a  scoop  (Fig.  149)  for  dislodging  the  calculus  from 


Fig.  149. 


Calculus  scoop. 


a  sacculation,  for  removing  debris,  etc. ;  a  catheter  en  chemise,  or  a 
Buckston-Browne  air-tampon,  for  controlling  hemorrhage,  should  it 
be  excessive. 

The  catheter  en  chemise  is  made  by  passing  a  gum  catheter 
through  the  centre  of  a  piece  of  gauze  or  muslin  four  inches  square ; 
the  muslin  is  slipped  along  the  catheter  till  it  is  about  one  inch  from 
its  eye  ;  it  is  then  firmly  wrapped  with  silk  .about  the  point  of  punc- 
ture, thus  securing  it  in  place  and  allowing  the  muslin  or  gauze  to 
hang  free  as  would  a  petticoat.  When  needed  to  stop  bleeding,  this 
catheter  is  passed  into  the  bladder  through  the  wound,  and  the  space 
intervening  between  the  muslin  and  the  catheter  shaft  is  then  packed 
with  iodoform  or  other  antiseptic  gauze.  Buckston-Browne's  air- 
tampon  acts  as  does  the  Barnes  bag,  being  inflated  after  it  has  been 
put  in  position  :  the  air-bag  surrounds  a  catheter. 

A  lithotrite  should  be  provided,  in  case  the  stone  should  be  too 
large  to  be  removed  whole,  and  also  the  surgical  instruments  required 
in  all  cutting  operations, — i.e.,  haemostatic  forceps,  tenacula,  grooved 
director,  and  probe.  Preliminary  disinfection  of  the  urethra  and  the 
operative  region  having  been  accomphshed,  and  the  rectum  having 
been  emptied,  the  patient,  thoroughly  anaesthetized,  is  placed  on  the 
table,  and  previous  to  operation  the  stone  is  again  sought  for.     Unless 


CALCULUS  OF  THE  BLADDEE.  457 

it  is  found  at  this  time,  tlie  operation  should  be  postponed.  If  it  is 
detected,  the  urine  is  drawn  by  a  catheter,  and  from  six  to  eight 
ounces  of  boric  acid  solution  or  other  antiseptic  are  injected  ;  the 
patient  is  then  brought  to  the  edge  of  the  table  with  his  thighs  well 
separated  and  flexed  on  the  abdomen  and  the  legs  flexed  on  the 
thighs,  the  position  being  maintained  either  by  assistants  or  by  me- 
chanical contrivances.  The  buttocks  should  project  slightly  over  the 
end  of  the  table.  The  grooved  staff  is  then  passed  into  the  urethra, 
and  if  possible  the  stone  is  again  felt  with  it.  Its  tip  being  well 
within  the  bladder,  the  curve  of  the  staff  is  pulled  up  against  the 
symphysis  ;  its  shaft  should  be  exactly  in  the  middle  hne  or  inclined  a 
little  towards  the  right  groin.  The  surgeon,  having  placed  the  staff  as 
he  wishes  it,  directs  an  assistant  to  hold  it  exactly  in  this  position. 
The  incision  is  made  from  a  point  an  inch  and  a  quarter  in  front  of 
the  anus  and  a  little  to  the  left  of  the  raphe,  downward  and  outward 
for  three  inches,  to  about  the  middle  of  the  space  between  the  anus 
and  the  tuberosity  of  the  ischium,  inclining  slightly  more  towards  the 
ischium  to  avoid  injuring  the  rectum.  The  first  incision  is  deeper 
anteriorly,  and  divides  the  skin,  superficial  fascia,  transverse  perineal 
muscle,  a  few  posterior  fibres  of  the  accelerator  uringe,  branches  of 
the  superficial  perineal  vessels  and  nerve,  and  the  inferior  edge  of  the 
superficial  layer  of  the  triangular  ligament ;  at  the  posterior  portion 
of  the  incision  the  inferior  hemorrhoidal  vessels  and  nerves  are  laid 
bare.  All  freely  bleeding  vessels  are  at  once  secured  by  haemostatic 
forceps,  which  are  not  removed  till  the  operation  is  completed.  The 
space  containing  the  membranous  urethra  bounded  by  the  superficial 
and  deep  layers  of  the  triangular  ligament  having  been  thus  opened, 
the  surgeon  introduces  his  finger  into  the  wound  and  feels  for  the 
groove  of  the  staff.  Finding  it,  and  with  his  left  forefinger  as  a  guide, 
the  point  of  the  knife  is  passed  into  the  groove,  and,  by  either  pushing 
the  staff  and  knife  backward  together  or  following  the  groove  with  the 
point  of  the  knife,  the  bladder  is  entered  at  its  neck.  To  extract  the 
calculus  easily  it  is  necessary  to  incise  the  left  lobe  of  the  prostate : 
this  is  accomplished  by  depressing  the  knife  so  that  the  greatest  cut- 
ting pressure  is  brought  to  bear  on  the  heel  of  the  blade.  The  blade 
of  the  knife  should  be  kept  parallel  with  the  external  wound.  This 
cut  divides  the  deep  layer  of  the  triangular  ligament,  the  anterior 
fibres  of  the  levator  ani,  a  portion  of  the  compressor  urethree  muscle, 
the  left  lobe  of  the  prostate,  the  membranous  and  the  prostatic 
urethra,  and  nicks  the  vesical  neck.  A  deep  incision  into  the  neck 
of  the  bladder  may  cause  serious  hemorrhage  from  wounding  of  the 
prostatic  plexus  of  veins,  or,  by  opening  the  recto-vesical  fascia,  may 


468  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

allow  of  urinary  infiltration.  If  the  staff  is  kept  well  up  against  the 
pubis  and  the  blade  of  the  knife  is  not  permitted  to  leave  its  groove, 
the  incision  into  the  prostate  and  the  neck  of  the  bladder  is  not 
likely  to  be  too  deep.  The  entrance  of  the  knife  into  the  bladder  is 
marked  by  a  rush  of  urine  or  of  the  fluid  injected.  The  prostatic 
wound  may  be  enlarged  during  the  withdrawal  of  the  knife,  endan- 
gering the  rectum.  The  better  plan  is  to  make  the  wound  as  free  as 
is  required,  by  depressing  the  handle  during  the  passage  of  the  knife 
inward,  when  its  tip  is  engaged  in  the  groove  of  the  staff.  Having 
thus  opened  the  prostatic  urethra  and  the  vesical  neck,  the  left  fore- 
finger of  the  operator,  guided  by  the  groove  of  the  staff,  is  introduced 
into  the  bladder ;  when  the  stone  is  felt  the  staff  is  withdrawn. 

The  operator's  finger  being  within  the  bladder,  the  closed  forceps 
is  introduced  along  this  as  a  guide  until  the  blades  are  well  inside. 
It  is  then  opened  and  rotated  on  its  long  axis  to  the  right,  thus  en- 
abhng  the  right-hand  blade  to  act  as  a  scoop,  which  slides  beneath 
the  calculus.  When  the  stone  is  firmly  grasped  in  the  forceps  it  is 
removed  by  traction  made  upward  and  forward  in  the  line  of  the 
pelvic  axis.  A  slight  rocking  motion  often  assists  in  its  delivery. 
When  the  stone  is  oblong  or  irregular  in  shape  it  is  important  so  to 
grasp  it  that  its  smallest  dimensions  shall  be  presented  to  the  opening. 

In  children  the  use  of  a  blunt  gorget — i.e.,  a  broad,  straight- 
bladed  knife  with  a  blunt  probe-point  which  follows  the  groove  of  the 
staff — is  of  use,  owing  to  the  prostate  being  a  rudimentary  body  and 
the  vesical  neck  not  being  of  sufficient  size  to  allow  of  the  introduc- 
tion of  the  finger.  The  forceps,  guarded  by  the  flat  surface  of  the 
gorget,  are  introduced,  with  somewhat  more  of  an  inclination  towards 
the  symphysis  than  in  the  adult,  owing  to  the  relatively  high  position 
of  the  bladder  in  children. 

Failure  to  find  the  calculus  at  the  first  trial  may  be  due  to  its 
lodgement  behind  the  prostate.  Repeating  the  attempt  and  meeting 
with  no  success,  the  curved  forceps  should  be  substituted  and  intro- 
duced with  the  points  downward  and  the  handle  slightly  raised,  when 
the  calculus  will  usually  be  found.  If  the  calculus  cannot  be  removed, 
owing  to  the  edges  of  the  wound  overlapping,  the  fingers  may  be  used 
as  retractors  or  a  sufficient  incision  made  with  the  probe-pointed  knife, 
the  incision  being  preferable  to  tearing  the  wound  in  the  effort  of  ex- 
traction. The  bladder  should  be  explored  with  either  the  finger  or  a 
sound  after  the  stone  has  been  extracted,  to  be  certain  that  no  other 
stone  remains.  Every  portion  of  its  walls  should  be  felt.  This  is 
accomplished  by  making  suprapubic  pressure  while  the  examining 
finder  is  in  the  bladder. 


CALCULUS  OF  THE  BLADDEK.  469 

Soft  calculi,  by  breaking  into  several  pieces  from  the  pressure  of 
the  forceps,  usually  prolong  the  operation  and  necessitate  the  use  of  a 
scoop  and  careful  irrigation  in  order  that  all  the  fragments  nftay  be 
removed.  Sometimes,  in  spite  of  every  precaution,  a  small  fragment 
remains,  forming  a  nidus  for  new^  concretions,  thereby  necessitating 
a  second  operation.  Recurrence  of  stone,  hov^ever,  does  not  prove 
that  operation  v^as  incomplete,  this  frequently  taking  place  vvrhen  it  is 
absolutely  certain  that  the  bladder  has  been  emptied. 

Other  complications  may  occur.  Among  them  is  excessive  hem- 
orrhage following  the  first  incision,  and  due  to  wounding  of  the 
artery  of  the  bulb,  either  from  its  anomalous  position  or  because  the 
incision  is  carried  too  far  forward ;  or  the  distended  hemorrhoidal 
vessels  may  be  the  source  of  the  bleeding.  Hemorrhage  from  such 
a  source  is  easily  controlled  by  means  of  haemostatic  forceps,  re- 
placed by  ligatures  at  the  termination  of  the  operation  if  the  bleeding 
continues. 

Hemorrhage  from  the  deeper  incision  is  rarely  profuse,  and 
usually  stops  from  the  pressure  of  the  fmgers  or  of  the  instruments 
introduced.  These  proving  insufficient,  a  catheter  en  chemise,  or  a 
Buckston-Browne  tampon,  may  be  inserted  after  the  removal  of  the 
calculus  ;  this  usually  controls  it. 

Through  careless  manipulation  the  staff  may  not  enter  the  blad- 
der, but  may  be  caught  in  a  pouch  of  the  urethra.  Should  such  an 
accident  occur,  the  staff  should  be  withdrawn  and  reintroduced  until 
it  is  brought  in  contact  with  the  stone. 

It  has  happened  in  lithotomies  performed  on  children  that,  owing 
to  the  small  size  of  the  incision  in  the  vesical  neck  and  the  prostate, 
efforts  at  introducing  the  finger  into  the  bladder  have  resulted  in 
tearing  the  membranous  urethra  completely  across  and  pushing  the 
bladder  up  out  of  the  pelvis.  Such  an  accident  demands  suprapubic 
cystotomy,  the  passage  of  a  catheter  from  the  bladder  out  through 
the  urethra,  and  the  suturing  of  the  torn  ends  of  the  urethra. 

Wounding  the  rectum,  due  to  insufficient  lateralization  of  the 
knife,  sometimes  occurs ;  the  wound  usually  heals  spontaneously, 
though  a  fistula  may  follow.  To  guard  against  such  a  result,  the 
rectal  wound  should  be  stitched  as  soon  as  discovered. 

Peritonitis  has  resulted  from  opening  the  posterior  wall  of  a  con- 
tracted bladder:  to  obviate  such  an  accident,  the  bladder  should  be 
moderately  distended  with  fluid,  and  the  knife  should  not  be  carried 
too  far  forward  into  the  wound. 

The  perineum  may  be  so  deep  that  it  will  be  impossible  to  in- 
troduce the  finger  into  the  bladder  to  guide  the  forceps  to  the, stone. 


470  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

Should  such  perineal  depth  be  anticipated,  some  other  operation 
should  be  chosen.  When  this  condition  is  discovered  after  the  in- 
cision has  been  made,  a  blunt  gorget,  with  thin  but  not  sharp  edges, 
may  be  used  to  guide  the  forceps,  the  gorget  being  withdrawn  as  soon 
as  the  stone  is  grasped. 

Formerly  the  gorget  was  considered  an  instrument  of  necessity  in 
all  lithotomies,  as  was  a  broad  probe-pointed  knife  used  in  making 
the  prostatic  wound.  At  present  it  serves  as  a  guide  to  the  passage 
of  other  instruments  into  the  bladder,  its  edges  not  being  sharp.  It 
is  also  used  to  enlarge  the  wound  in  the  prostate,  its  point  being 
engaged  in  the  groove  of  the  staff ;  in  this  case  its  edges  should 
be  sharp. 

Prostatic  enlargement  may  necessitate  the  use  of  the  gorget 
instead  of  the  finger  as  a  guide.  In  these  cases  there  may  be  such 
extreme  rigidity  of  the  neck  of  the  bladder  that  full  dilatation  of  the 
prostatic  urethra  will  be  required  before  instruments  for  the  extraction 
of  the  stone  can  be  passed.  A  pair  of  straight  or  curved  Spencer- 
Wells  forceps,  opened  out  after  introduction  into  the  wound  along  the 
groove  of  the  staff,  is  then  serviceable.  Forcible  dilatation  of  the 
prostatic  urethra  has  been  followed  by  complete  disappearance  of  the 
urinary  symptoms. 

It  may  be  hard  to  complete  the  operation  because  of  the  size  of 
the  stone.  A  calculus  over  two  inches  in  diameter  could  scarcely  be 
removed  through  the  perineal  opening  unless  the  incision  were 
dangerously  large  or  the  tissues  seriously  bruised.  Bimanual  pal- 
pation should  always  detect  a  stone  of  this  size,  and  should  prevent 
the  surgeon  from  making  efforts  at  removal  by  perineal  operation. 
In  case  previous  examination  has  been  neglected  and  the  bladder  is 
already  open,  the  stone  may  be  crushed  and  removed  in  fragments. 

Sacculation  may  make  the  operation  difficult.  The  stone  may  be 
freed  from  its  fixed  position  by  stretching  the  opening  in  the  sac  by 
means  of  the  finger  or  by  notching  it  in  several  places  with  a  blunt- 
pointed  knife.  It  is  often  impossible  to  remove  a  sacculated  stone 
through  a  perineal  opening :  the  high  operation  should  then  be  per-, 
formed. 

After- Treatment  of  Perineal  Lithotomy  Cases. — The  bladder,  having 
been  cleared  of  calcuh  and  incrustations,  should  be  well  irrigated 
with  hot  sterile  water  (110°  F.).  This  removes  small  fragments  and 
clots  and  serves  to  control  hemorrhage. 

Should  hemorrhage  from  the  bladder-neck  or  the  prostate  persist, 
the  air-tampon  or  the  catheter  en  chemise  is  inserted.  This  may  be 
removed  within  seventy-two  hours. 


CALCULUS  OF  THE  BLADDER.  471 

When  there  is  cystitis,  particularly  if  this  is  of  long  standing,  peri- 
neal drainage  is  indicated.  This  is  best  secured  by  a  full-sized  gum 
catheter  (30  F.)  the  tip  of  which  lies  just  within  the  vesical  sphincter. 
A  rubber  tube  conveys  the  urine  to  a  vessel  under  the  bed  or  at  a 
lower  level  than  the  bladder,  the  free  end  of  the  tube  being  sub- 
merged in  an  antiseptic  solution.  A  light  gauze  dressing  and  a  T- 
bandage  complete  the  toilet  of  the  wound,  drainage  being  continued 
until  the  urine  is  clear,  usually  from  three  to  eight  days.  The  cath- 
eter is  changed  every  second  day  ;  the  bladder  is  irrigated  twice 
daily,  and  each  time  this  is  done  the  gauze  dressing  is  changed. 

Should  there  not  have  been  cystitis,  artificial  drainage  is  unneces- 
sary ;  if  hemorrhage  does  not  require  packing  of  the  wound,  a  pad 
of  iodoform  gauze  is  loosely  applied  to  the  perineum,  care  being  taken 
that  it  does  not  prevent  the  free  escape  of  the  urine  from  the  wound. 
This  escape  continues  for  several  days,  and  then  stops  for  a  day  or 
two,  owing  to  inflammatory  swelling,  then  is  again  noticed,  but  be- 
comes less  marked  till  it  ceases  on  final  closure  of  the  deep  wound. 

The  patient  should  lie  on  his  back  in  bed,  suitable  absorbent 
material  (pillows  of  oakum  enclosed  in  one  layer  of  gauze,  and  fre- 
quently changed)  should  be  placed  so  that  it  will  catch  the  urine,  and 
his  thighs  and  buttocks  protected  from  irritation  by  the  urine  by 
alcohol  baths  followed  by  liberal  applications  of  thick  zinc  ointment, 
boric  ointment,  or  carbolated  cosmoline. 

Immediate  suture  of  the  perineal  incision  has  been  tried,  but  is 
attended  with  great  risks,  owing  to  the  fact  that  the  deeper  portion 
of  the  wound,  being  more  or  less  bruised  by  instruments,  may  slough, 
and  in  the  absence  of  drainage  cause  cellulitis.  If  the  wound  is 
allowed  to  remain  open  and  heal  slowly,  granulation  proceeds  from 
the  bottom  surfaceward. 

The  patient  should  remain  in  bed  from  four  to  twenty-eight  days, 
according  to  the  rapidity  with  which  the  wound  closes.  In  children 
closure  of  the  wound  takes  place  rapidly. 

Median  Lithotomy. — In  this  operation  the  line  of  incision  follows 
the  raphe  between  the  scrotum  and  the  anus.  The  patient  being  in 
the  same  position  as  for  lateral  lithotomy,  a  staff  grooved  on  its 
under  surface  is  introduced  and  held  with  its  shaft  at  right  angles  to 
the  plane  of  the  body,  its  curve  hooked  up  under  the  symphysis  pubis. 
The  point  of  the  knife — preferably  a  narrow  straight  bistoury — is  in- 
serted at  the  perineal  centre  just  posterior  to  the  bulb  of  the  urethra,  and 
pushed  on  until  its  point  engages  the  groove  of  the  staff  at  the  mem^ 
branous  urethra,  where  an  incision  is  made  about  an  inch  in  length. 

The  surgeon  introduces  his  left  forefinger  into  the  wound  and 


472  genito-ukijstaey  diseases  and  syphilis. 

carries  it  through  the  prostatic  urethra  into  the  bladder.  The  staff  is 
withdrawn  and  the  forceps  introduced.  Should  the  parts  resist  the 
introduction  of  the  finger,  the  prostatic  urethra  should  be  dilated  by 
means  of  Dolbeau's  dilator.  It  is  best  to  overcome  the  resistance  of 
the  parts  with  the  fmger,  owing  to  the  danger  of  laceration  in  using 
instruments.  A  grooved  director  may  be  introduced  along  the  staff 
before  its  withdrawal,  the  finger  following  the  director,  thereby  allow- 
ing more  room.  The  incision  divides  the  skin,  the  superficial  fascia, 
the  sphincter  ani,  the  lower  edge  of  the  triangular  ligament,  the 
compressor  urethrse,  the  membranous  urethra,  and  the  apex  of  the 
prostate.   No  vessels  of  any  size  are  encountered. 

The  advantages  claimed  for  this  operation  are  that  there  is  no  risk 
of  injury  to  the  seminal  vesicles  or  the  ejaculatory  ducts,  and  that, 
no  arteries  of  any  size  being  divided,  the  hemorrhage  is  slight.  There 
is  some  risk,  however,  of  wounding  the  bulb  of  the  urethra,  an  acci- 
dent the  dangers  of  which  are  much  exaggerated. 

Dolbeau  modified  the  median  operation  by  introducing  a  lithotrite 
through  the  wound,  crushing  the  stone,  and  washing  out  the  frag- 
ments at  one  sitting.  Owing  to  the  development  of  litholapaxy,  his 
operation  has  fallen  into  disuse. 

Bilateral  Lithotomy. — The  incision  is  crescentic,  the  centre  of 
the  curve  lying  from  one-half  to  three-quarters  of  an  inch  in  front  of 
the  anus,  and  its  arms  extending  on  each  side  to  a  point  midway  be- 
tween the  anus  and  the  tuber  ischii.  The  incision  is  deepened  till 
the  membranous  urethra  is  exposed.  The  urethra  is  opened  in  the 
groove  of  the  staff,  and  Dupuytren's  curved  double  lithotome  cache 
is  introduced  along  the  staff  into  the  bladder.  This  instrument  has 
the  curve  of  a  sound,  and  is  provided  with  two  sharp  blades,  capable 
of  divergence  from  the  staff,  so  that  after  introduction  into  the  bladdei 
through  the  urethra  they  may  be  expanded.  Upon  the  withdrawal 
of  the  opened  instrument  a  wide  incision  is  made  in  both  lateral 
lobes  of  the  prostate.  When  the  lithotome  touches  the  stone  in  the 
bladder  it  is  turned  with  its  curve  downward,  and  the  staff  is  with- 
drawn ;  the  blades  are  then  opened  to  the  desired  width,  and  the  in- 
strument is  withdrawn,  the  lobes  of  the  prostate  being  divided  from 
within  outward.  As  the  instrument  is  withdrawn  it  should  be  kept 
exactly  in  the  middle  hne,  and  its  handle  should  be  slightly  depressed. 
The  finger  is  then  introduced  into  the  bladder  as  a  guide  to  the 
forceps,  and  the  stone  is  extracted  as  by  the  lateral  method. 

The  advantages  claimed  for  bilateral  lithotomy  are  the  free  en- 
trance into  the  bladder  and  the  lessened  danger  of  wounding  the 
"larger  blood-vessels. 


CALCULUS  OF  THE  BLADDEK.  473 

Medio-bilateral  Lithotomy. — Civiale's  operation  is  a  modification 
of  the  preceding.  The  first  incision,  made  in  the  median  hne,  is 
deepened  until  the  membranous  urethra  is  opened,  care  being  taken 
not  to  wound  the  bulb. 

A  straight  lithotome  is  then  introduced,  which  upon  its  withdrawal 
divides  both  lobes  of  the  prostate  as  in  the  bilateral  method. 

The  bilateral  and  medic-bilateral  operations  are  not  practised  to 
any  great  extent  at  present,  partly  because  they  give  but  little  more 
room  than  the  median  and  lateral  operations,  mainly  because  they 
require  a  special  instrument. 

Perineal  lithotomy  is  indicated  for  the  removal  of  small  hard 
stones  which  cannot  be  crushed.  The  lateral  operation  is  the  one 
of  choice.  If  there  is  a  dense  stricture  of  the  membranous  urethra, 
or  if  the  stone  is  not  more  than  half  an  inch  in  diameter,  median 
lithotomy  is  indicated ;  should  this  not  give  sufficient  room,  the 
lateral  lobes  of  the  prostate  may  be  nicked  by  a  blunt-ended  knife  or 
the  straight  double-bladed  lithotome. 

The  sequelae  of  Kthotomy  are  much  the  same  as  those  of  lithotrity  ,• 
there  is,  of  course,  greater  likelihood  of  troublesome  hemorrhages 
from  the  prostatic  plexus,  and  of  infiltration  and  cellulitis  of  the 
pelvic  cellular  tissues,  because  of  the  incision  carried  through  the 
prostate.  Shock,  collapse,  urinary  fever,  thrombosis  of  the  pelvic 
veins,  septicaemia,  pyaemia,  and  peritonitis  have  all  been  recorded  as 
following  perineal  lithotomy. 

As  remote  sequelae,  vesico-rectal  or  urethro-rectal  fistulas,  vesical 
or  urethral  fistulae,  and  sterility  are  possible.  Though  it  would  seem 
difficult  to  wound  and  obliterate  both  ejaculatory  ducts  in  the  operation 
of  lateral  lithotomy,  there  is  sufficient  cMnical  evidence  that  this  some- 
times occurs. 

Suprapubic  Lithotomy. — Pierre  Franco  in  1561  is  credited  as 
having  been  the  first  to  extract  a  calculus  through  an  opening  above 
fhe  pubis.  He  deemed  the  operation  too  dangerous  to  be  repeated, 
and  performed  it  only  as  a  last  resort.  The  first  to  perform  it  in  this 
country — according  to  Agnew — was  Professor  Gibson,  of  the  Univer- 
sity of  Pennsylvania.     Unfortunately,  the  case  died  from  peritonitis. 

With  the  advent  of  methods  by  which  the  extraperitoneal  anterior 
portion  of  the  bladder  was  made  accessible,  the  suprapubic  operation 
has  gained  in  favor,  and  is  distinctly  indicated  for  the  extraction  of 
stones  which  are  encysted  or  are  too  hard  and  large  for  lithotrity. 
(Figs.  151-153.) 

In  preparing  for  operation  the  suprapubic  and  perineal  regions, 
the  penis,  scrotum,  and  urethra  should  be  thoroughly  cleansed  as  for 


474  GEXITO-rRIXAEY   DISEASES   AXD   SYPHILIS. 

any  formal  surgical  procedure.  The  rectum  is  emptied  by  an  enema 
just  before  the  operation. 

The  patient,  having  been  anaesthetized,  is  placed  flat  upon  his 
back,  with  the  pelvis  and  shoulders  slightly  raised  to  relax  the 
abdominal  muscles.  The  operating-table  should  be  so  arranged  that 
the  patient  can  in  a  moment  be  placed  in  the  Trendelenburg  position, 
should  this  be  required.  The  varying  relations  of  the  peritoneum 
to  the  parietes  of  the  hypogastric  region,  in  accordance  with  vesical 
distention,  have  been  already  noted.  Distention  of  the  bladder  rolls 
back  the  loosely  attached  peritoneum  and  exposes  considerable 
bladder-wall  not  covered  by  that  membrane.  Distending  the  rectum 
elevates  the  posterior  portion  of  the  bladder. 

Distention  of  both  bladder  and  rectum  hfts  the  bladder  up  against 
the  pubic  walls  anteriorly,  and,  since  it  cannot  sink  down  into  the 
perineum,  it  stretches  up  into  the  abdominal  cavity.     (Fig.  150.) 

The  device  for  increasing  the  peritoneo-pubic  space  by  distention 
of  both  bladder  and  rectum  is  known  as  the  "  Garson-Petersen 
method,"  and  by  it  this  space  is  increased  to  its  utmost  extent. 

For  the  distention  of  the  rectum  a  dilatable  rubber  bag, — "  Peter- 
sen's rectal  colpeurynter,"— -collapsed  and  well  oiled,  is  introduced 
into  the  rectum  above  the  sphincters.  The  bladder  is  then  emptied, 
and  washed  out  with  warm  boric  solution,  and  the  rectal  bag  is  dilated 
to  the  required  extent ;  usuahy  eight  ounces  of  fluid  are  forced  in. 
A  quantity  greater  than  this  may  cause  laceration  of  the  rectum. 
Following  the  dilatation  of  the  rectum  the  bladder  should  be  injected. 
From  eight  to  ten  ounces  usually  suffice  for  adults.  The  gauge  of 
the  amount  to  be  injected  is  the  pressure  on  the  bulb  of  the  syringe  or 
the  height  to  which  the  bladder  rises  above  the  pubis.  Fluid  should 
never  be  injected  forcibly. 

In  children  the  amount  injected  should  depend  upon  the  age  of 
the  patient  and  the  size  of  the  lower  bowel.  Four  ounces  are  enough. 
Owing  to  the  fact  that  in  early  life  the  bladder  is  an  abdominal  rather 
than  a  pelvic  organ,  injections  of  this  viscus  and  the  Trendelenbui^ 
position  will  frequently  accomplish  the  desired  displacement,  disten- 
tion of  the  rectum  being  unnecessary. 

There  have  been  so  many  reported  cases  of  rectal  rupture  follow- 
ing the  use  of  the  colpeurynter  that  most  surgeons  absolutely  reject 
this  appliance,  holding  that  moderate  injection  of  the  bladder  and 
elevation  of  the  pelvis  will  give  the  desired  room. 

The  bladder  and  the  rectum  having  been  distended,  an  incision  is 
made  from  a  little  below  the  upper  margin  of  the  pubis  upward  in 
the  median  line  of  the  abdomen  for  three  inches.     The  cut  is  carried 


CD 

to      & 

B   5. 


CALCULUS  OF  THE  BLADDEE.  475 

down  in  the  middle  line  between  the  recti  and  pyramidales  muscles, 
dividing  the  sheath  of  the  rectus  and  the  layer  of  transversahs  fascia 
which  bounds  the  prevesical  space  anteriorly  ;  the  posterior  layer  of 
this  fascia  should  prevent  the  peritoneum  from  being  seen.  The  pre- 
vesical fat,  having  been  exposed,  is  stripped  upward  and  backward, 
carrying  the  peritoneum  with  it ;  unnecessary  tearing  or  bruising  of 
this  fibro-adipose  tissue  favors  urinary  infiltration  and  prevesical  sup- 
puration. Even  under  the  most  favorable  circumstances  infection  of 
this  loose  tissue  is  likely  to  take  place ;  when  the  bladder  is  infected 
the  danger  is,  of  course,  much  greater. 

To  avoid  prevesical  abscess  in  cases  of  septic  cystitis,  Senn  advises 
that  the  operation  be  performed  in  two  stages.  After  exposing  the 
anterior  bladder- wall  and  arresting  hemorrhage,  the  wound  is  packed 
with  iodoform  gauze  and  dressed  antiseptically.  At  the  end  of  five 
days  the  dressing  is  removed,  and,  if  the  wound  has  remained  free 
from  infection,  it  will  be  found  covered  with  healthy  granulations, 
which  close  all  channels  of  communication  between  the  wound  and 
the  prevesical  space.  The  bladder  is  then  opened  and  drained  in 
the  ordinary  manner.  Local  anaesthesia  with  cocaine  is  sufficient 
for  the  secondary  operation. 

When  the  operation  is  completed  at  one  sitting,  the  prevesical  space 
is  flushed  with  protargol  solution  1  to  2000,  and  the  bladder-wall, 
having  been  clearly  exposed,  is  hooked  up  by  a  tenaculum  and  an 
incision  is  made  large  enough  to  admit  the  index  finger.  Through 
each  border  of  the  bladder-opening  a  thread  is  passed,  by  means  of 
which  the  wound  can  be  held  forward  and  kept  open.  Should  it  be 
necessary  to  enlarge  the  opening,  this  may  be  done  with  a  probe- 
pointed  bistoury.  By  placing  the  patient  in  the  Trendelenburg  posi- 
tion and  using  an  electric  light  the  entire  bladder,  including  the  vesical 
opening  of  the  urethra,  can  be  inspected  in  patients  who  are  not 
unduly  fat.  The  calculus  is  removed  by  the  scoop  or  forceps  ;  if  it  is 
encysted,  it  should  be  shelled  out  with  extreme  gentleness,  the  opening 
into  the  bladder  from  the  diverticulum  being  nicked  and  stretched 
should  this  be  necessary.  After  removing  the  major  calculus,  search 
should  be  made  for  any  remaining  calculi  or  fragments.  Some  stones 
are  so  large  that  the  parietal  incision  may  be  too  small  for  their 
delivery  (Fig.  151) ;  one  or  both  recti  tendons  should  then  be  cut. 

The  condition  of  the  prostate  should  be  noted,  and  any  small  out- 
growths preventing  the  outflow  of  urine  should  be  removed,  since 
they  are  predisposing  factors  to  calculus-formation  ;  their  removal 
lessens  the  chance  of  recurrence  and  frequently  relieves  troublesome 
urinary  symptoms. 


476 


GENITO-UKINARY  DISEASES   AND   SYPHILIS. 
Fig.  152. 


Uric  acid  calculus.    Exact  size.  Weight,  nine  and  one  half  ounces.   Kemoved  by  suprapubic  section. 


Fig.  153. 


"%X. 


•C*     „-' 


Uric  acid  calculus.   Exact  size.   Weight,  nine  and  one-half  ounces.   Removed  b7  suprapubic  section. 


CALCULUS  OF  THE  BLADDER. 


477' 


After- Treatment  of  Suprapubic  Lithotomy  Cases. — The  after-treat- 
ment of  the  bladder,  the  stone  having  been  removed,  depends  upon 
the  condition  of  its  walls.  Provided  these  are  in  a  fairly  healthy  con- 
dition, immediate  suture  of  the  bladder-wound  is  safe.  When  the 
surgeon  believes  before  operation  that  the  case  is  one  for  immediate 
suture  of  the  vesical  wound,  it  is  well  not  to  carry  the  incision  of  the 
bladder-wall  too  close  to  the  pubis,  for  when  the  bladder  collapses  the 
wound  may  be  inaccessible. 

A  double  line  of  sutures  should  be  used :  the  first,  a  running  stitch 
of  fme  catgut,  approximates  the  cut  edges  or  raw  surfaces  of  the 
mucous  membrane  ;  the  knots  should  be  placed  on  the  vesical  aspect 
of  the  bladder;  the  second,  an  interrupted  suture  of  fine  catgut,  six  to 
the  inch,  includes  everything  down  to  the  mucous  membrane.  To 
determine  whether  or  not  the  lines  of  suture  are  tight  enough,  the 

Fig.  154. 


Cushing's  suture  for  closing  the  bladder. 


wound  may  be  filled  with  water  and  the  bladder  distended  with  air ; 
any  leakage  will  become  at  once  apparent.  Should  there  be  doubt  as 
to  leakage,  the  prevesical  space  may  be  drained  for  forty-eight  hours 
by  a  drainage-tube.  When  the  bladder  is  infected,  provision  against 
the  bladder  stitches  failing  to  hold  should  be  made  by  gauze  drainage 
of  the  prevesical  space.  This  should  be  removed  on  the  third  day, 
provided  the  bladder  suture  holds  and  the  prevesical  space  remains 
clean,  the  parietal  wound  then  being  closed  by  sutures  placed  but  not 
tied  down  at  the  time  of  operation. 

After  bladder  suture  continuous  catheterization  is  indicated  for 
from  three  to  five  days,  supplemented  by  instillations  of  mild  antisep- 
tics if  there  is  moderate  cystitis  ;  injections  should  be  avoided. 

Should  there  be  marked  cystitis  and  the  bladder-walls  be  in  an  un- 
healthy condition,  suture  of  the  vesical  wound  is  not  advised.  In  such 
cases  drainage  should  be  secured  through  the  wound  until  the  urine 


478 


GENITO-URINAKY  DISEASES  AND   SYPHILIS. 


becomes  clear  or  is  passed  normally  through  the  urethra.  To  facilitate 
irrigation,  two  tubes  passing  to  the  base  of  the  bladder  and  fenes- 
trated for  an  inch  only,  are  stitched  to  the  most  dependent  part  of  the 
parietal  wound ;  in  case  one  should  become  clogged  the  other  is 
available.  The  bladder-incision  is  sutured  tightly  about  these  tubes  ; 
unless  this  is  done  the  surface  of  the  wound  is  constantly  bathed  in 
urine.     To  prevent  this,  Cobbe  has  suggested  capillary  drainage.     A 


Gibson's  method  of  closing  the  bladder. 


single  glass  tube  is  introduced  through  the  suprapubic  incision,  its 
rounded  end  reaching  to  the  most  dependent  part  of  the  bladder 
when  the  patient  is  in  the  dorsal  decubitus.  This  glass  drainage-tube 
is  attached  to  a  rubber  tube,  which  is  conducted  into  a  bottle  of  anti- 
septic solution  placed  at  the  bedside.  Through  these  tubes  is  run  a 
long  wick  of  iodoform  gauze.  This  capillary  drainage,  though  par- 
tially successful,  will  not  keep  the  wound  dry. 


CALCULUS  OF  THE  BLADDER. 


479 


Gibson  drains  the  bladder  by  securing  its  wall  closely  around  the 
rubber  tube  by  a  single  Lembert  suture  on  each  side.  (Fig.  155,  A.) 
Two  inversion  sutures  are  placed  on  each  side  of  the  tube.  (Fig.  155,  B.) 
Two  others  are  then  introduced  similar  to  the  first.  (Fig.  156,  A.)  The 
ends  of  these  may  be  either  cut  or  left  long,  and  utilized  in  closing  the 
abdominal  wound  snugly  about  the  tube.  This  method  prevents  leak- 
age into  the  prevesical  space,  and  is  followed,  on  removal  of  the  tube, 


Gibson's  method  of  closing  the  bladder. 


by  prompt  closure  of  the  wound.    The  tube  drains  into  a  vessel  placed 
below  the  level  of  the  bladder. 

Intermittent  siphonage  is  a  more  efficient  method  of  drainage.  Daw- 
barn  accomplishes  this  by  a  large  fountain  syringe  and  a  glass  or  hard 
rubber  Y  connection.  A  catch  just  above  the  Y  in  the  tube  allows  the 
liquid  in  the  bag  to  flow  drop  by  drop.  When  the  trap,  a  loose  knot 
below  the  Y,  is  filled,  the  next  drop  starts  a  siphonage  which  creates  a 
vacuum  between  the  Y  and  the  bladder,  thus  emptying  the  latter.     A 


480 


GENITO-URINARY    DISEASES    AND    SYPHILIS. 


soft  rubber  catheter  cut  across  between  its  tip  and  eye  is  inserted  into 
the  bladder,  and  over  this  a  larger  drainage-tube  which  provides  for 
intravesical  atmospheric  pressure.  The  two  tubes  are  united  by  a 
stitch.     The  outer  tube  is  held  in  place  by  a  strip  of  adhesive  plaster 


Fig.  157. 


Dr.  Dawbarn's  method  of  suprapubic  blad- 
der-drainage:  A,  the  Y-tube;  B,  the  "trap;" 
this  is  made  by  simply  tying  a  knot ;  C,  a 
catheter  with  end  cut  off,  thus  making  two 
eyes;  D,,  artery  forceps;  a  fountain  syringe 
catch  does  as  well,  to  regulate  the  flow ;  F, 
short  piece  of  larger  tubing  ;  between  this  and 
the  catheter  air  enters  the  bladder  freely. 


Dr.  Dawbarn's  method  of  suprapubic  blad- 
der-drainage, showing  a  vacuum-bottle  intro- 
duced into  the  circuit :  E,  bottle  with  rubber 
stopjier  and  two  glass  tubes.  This  is  used  tem- 
porarily, at  any  time,  to  reckon  the  flow  ol 
urine  per  hour,  and  to  analyze  it  undiluted  by 
fluid  from  the  reservoir. 


passed  across  the  wound  and  secured  to  the  rubber  tube  by  a  stitcho 
The  inner  tube  is  attached  to  one  limb  of  the  Y.  The  bladder  may  be 
washed  by  loosening  the  clamp  about  the  Y  and  pinching  the  tube 
below  it.  By  then  pinching  above  the  Y  and  releasing  tlie  tube  below, 
the  solution  flows  out.     In  order  to  secure  the  urine  undihited,  it  is  only 


CALCULUS  OF  THE  BLADDER.  481 

necessary  to  interpose  between  the  Y  and  the  bladder  a  large  flask  with 
a  tightly  fitting  rubber  stopper  pierced  by  two  glass  tubes.     (Fig.  157.) 

The  drainage-tubes  having  been  placed,  the  prevesical  space  is 
irrigated,  carefully  dried,  and  packed  with  iodoform  gauze,  the  upper 
part  of  the  abdominal  incision  is  closed  by  a  buried  catgut  suture 
through  the  fascia  and  muscles  and  a  superficial  interrupted  suture 
to  the  skin  and  underlying  fascia,  a  dry  dressing  is  applied  to  the 
wound,  the  skin  of  the  lower  abdomen  is  covered  with  a  thick  paste 
of  boric  or  zinc  ointment,  a  large  sterile  absorbing  dressing  of  gauze 
and  cotton  is  applied  to  the  hypogastric  region,  and  an  oakum  pad  is 
placed  beneath  the  patient's  buttocks.  The  bladder  should  be  irri- 
gated with  protargol  solution  and  the  packing  changed  every  four 
hours  when  the  urine  is  foul  and  constantly  escapes  into  the  wound. 

When  suprapubic  cystotomy  must  be  performed  for  calculus, 
under  circumstances  which  render  the  development  of  cellulitis  from 
infection  of  the  prevesical  space  probable,  it  would  seem  wise,  after 
having  irrigated  with  protargol  the  prevesical  space,  opened  the  blad- 
der, and  removed  the  stone,  to  close  the  bladder  by  suture,  even 
though.it  be  diseased,  thoroughly  cleanse  the- prevesical  space,  pack  it 
lightly  with  sterile'  gauze,  and  drain  the  bladder  by  permanent  cath- 
eterization or  by  median  perineal  urethrotomy.  If  the  bladder- 
stitching  is  carefully  performed,  even  though  definitive  union  does 
not  take  place,  the  prevesical  space  will  be  saved  from  constant 
soaking  with  septic  urine  for  at  least  three  or  four  days. 

Complications  and  Sequelae  of  Suprapubic  Cystotomy.— During  oper- 
ation there  may  be  troublesome  hemorrhage  ■  from  the  large  veins 
in  the  perivesical  tissue ;  these  are  readily  secured  by  hsemostatic 
forceps.  Removal  of  the  rectal  bag  and  evacuation  of  the  bladder- 
contents  are  indicated  when  bleeding  is  unusually  free  and  from  many 
points.;  under  these  circumstances  the  time  spent  in  trying  to  secure 
each  vessel  is  wasted,  since  the  bleeding  is  due  to  the  venous  en- 
gorgement caused  by  the  pressure  of  the  bag  and  the  vesical  tension. 
The  bladder-wall  may  bleed  freely  and  persistently,  requiring  the  ap- 
phcation  of  several  ligatures. 

The  peritoneum  may  be  opened ;  this  usually  occurs  before  the 
bladder  has  been  punctured  and  while  the  wound  is  still  sterile. 
The  opening  should  be  closed  at  once  by  a  fine  catgut  suture. 

Rupture  of  the  rectum  by  the  colpeurynter,  if  detected,  should  be 
treated  by  immediate  cceliotomy  and  suture. 

Shortly  following  suprapubic  cystotomy,  the  complications  common 
to  all  operations  on  the  urinary  tract  may  develop, — i.e.,  shock,  col- 
lapse, retention,  cellulitis,  septicaemia,  pyaemia,  etc. 

31 


482  GEXITO-rKIXARY   DISEASES   A:N^D   SYPHILIS. 

Prevesical  suppuration  is  a  common,  often  a  fatal,  sequel.  It 
develops  in  from  three  to  five  days,  sometimes  with  evident  symp- 
toms of  inflammation  and  suppuration, — i.e.,  local  tumor,  pain  and 
tenderness,  and  general  elevation  of  temperature.  Usually  the  onset 
of  this  compUcation  is  insidious,  the  condition  of  the  patient  suggest- 
ing ureemia  rather  than  suppuration ;  local  symptoms  are  but  slightly 
marked,  or  are  completely  absent,  and  the  temperature  is  normal 
or  subnormal. 

When  prevesical  suppuration  and  advancing  perivesical  cellulitis 
are  suspected,  the  suprapubic  wound  should  be  opened  freely,  the 
space  in  front  of  the  bladder  thoroughly  explored  and  drained,  and 
the  bladder  itself  drained  by  perineal  incision. 

The  suprapubic  wound  may  refuse  to  close,  leaving  a  fistula. 
This  rarely  happens  unless  there  is  obstruction  to  the  flow  of  urine 
through  the  urethra  or  the  suprapubic  wound  becomes  tubercular. 
The  treatment  is  that  generally  applicable  to  vesical  fistulae :  urethral 
obstruction  is  removed,  the  bladder  is  subjected  to  permanent  cathe- 
terization, and  the  fistulous  opening  is  cauterized. 

Hernia  sometimes  foUows  suprapubic  cystotomy,  the  cicatrix  of 
the  parietal  incision  yielding  to  intra-abdominal  pressure.  The 
transverse  cut  dividing  the  attachment  of  the  recti  muscles  is  much 
more  liable  to  be  followed  by  this  complication  than  is  the  ordinary 
vertical  incision.     It  is  treated  by  a  truss  or  by  radical  operation. 

When  the  bladder  is  sutured  by  silk  threads,  these  by  escaping 
into  the  vesical  cavity  may  form  foci  for  new  calculus-formations. 

Treatment  of  Vesical  Calculi  in  Women. — If  the  stone  is  quite 
small,  the  urethra  may  be  dilated  to  the  required  extent,  first  by 
suitable  dilatars,  then  by  the  little  finger.  This  being  done  very 
slowly,  there  will  be  but  little  laceration  of  the  mucous  membrane, 
and  the  incontinence  that  follows  mil  be  of  short  duration.  The  stone 
may  be  extracted  by  means  of  a  scoop  or  forceps.  If  the  stone  is  too 
large  to  be  removed  intact,  it  may  be  crushed  and  washed  out  in  the 
usual  manner.  If  too  large  and  too  hard  to  be  removed  in  this  way, 
or  if  the  bladder  requu-es  drainage,  vaginal  or  suprapubic  lithotomy 
is  indicated,  but  this  is  rarely  necessary.  Incision  of  the  urethra  and 
neck  of  the  bladder  should  never  be  employed  on  account  of  the  risk 
of  permanent  incontinence. 

Kelly  thus  performs  the  vaginal  operation:  The  patient  is  placed 
in  the  knee-chest  posture  ;  a  catheter  in  the  bladder,  or  speculum  in  the 
urethra  allows  air  distention  of  the  viscus.  The  posterior  vaginal  wall 
is  lifted  well  upward  towards  the  sacrum  by  means  of  a  Sims's  spec- 
ulum, and  the  anterior  vaginal  wall  is  brought  into  view.     An  incision 


CALCULUS  OF  THE  BLADDEK.  483 

into  the  bladder  is  made  through  the  vesicovaginal  septum.  The  slight 
hemorrhage  passes  into  the  bladder,  and  thus  the  field  of  operation  is 
kept  clear.  A  stone  in  the  bladder  or  lower  portion  of  the  ureter  may 
be  easily  removed  by  forceps  or  a  scoop. 

FOREIGN   BODIES   IN   THE   BLADDER. 

In  addition  to  calculi  there  has  been  found  in  the  bladder  an 
almost  unlimited  variety  of  foreign  bodies,  such  as  fragments  of 
catheter,  hair-pins,  pipe-stems,  lamp-wicks,  pencils,  spicules  of  bone, 
bullets,  shot,  etc.  These  may  enter  the  bladder  by  way  of  the 
urethra,  may  be  driven  into  the  viscus  by  direct  violence,  or  may 
gain  access  by  a  process  of  ulceration. 

Portions  of  catheter  are  more  frequently  found  in  the  bladder 
than  any  other  foreign  body.  The  breaking  of  a  soft  instrument  in 
the  urethra  or  bladder  usually  occurs  when  patients  catheterize  them- 
selves. Either  from  ignorance  or  from  carelessness,  they  continue  to 
use  a  catheter  after  it  has  become  weak  and  brittle. 

The  mechanism  by  which  foreign  bodies  introduced  into  the 
meatus  reach  the  bladder  has  been  described  in  considering  foreign 
bodies  in  the  urethra.  Often  the  introduction  of  these  bodies  is  sug- 
gested by  a  form  of  sexual  perversion.  Sometimes  they  are  passed  in 
for  the  purpose  of  allaying  the  intolerable  itching  and  burning  which 
are  symptom.atic  of  posterior  urethritis  and  are  referred  to  the  urethra 
just  behind  the  meatus. 

Foreign  bodies  driven  in  by  force  may  be  pieces  of  bone,  bullets, 
shot,  fragments  of  clothing,  sometimes  splinters  of  wood.  Foreign 
bodies  which  enter  the  bladder  by  the  process  of  ulceration  are  frag- 
ments of  bone  and  the  contents  of  the  intestinal  canal.  Dermoid  cysts 
and  extra-uterine  pregnancies  sometimes  discharge  into  the  bladder. 
Morris  says,  "  Among  surgical  catastrophies  and  miraculous  recov- 
eries is  the  case  of  a  pair  of  pressure  forceps  left  in  the  peritoneal 
cavity  at  an  ovariotomy,  in  which  ulceration  of  the  vesical  wall  oc- 
curred and  the  forceps  entered  the  bladder  and  were  then  success- 
fully removed  after  a  long  interval.'"  Morris  quotes  Guyon  and  Hen- 
riet  to  the  effect  that  a  foreign  body  once  fairly  within  the  cavity  of 
the  bladder  will  usually  occupy  a  transverse  position  between  the 
summit  and  the  neck  and  rather  nearer  the  neck.  In  the  empty 
bladder  this  is  the  only  position  which  bodies  not  longer  than  four 
inches  can  take.  A  body  five  inches  long  assumes  either  a  vertical 
or  an  oblique  position. 

.  Symptoms. — As  in  the  case  of  stone,  foreign  bodies  in  the  bladder 
may  remain  quiescent  for  a  long  period.     Commonly  they  produce 


484  GENITO-UEINAEY   DISEASES   AND    SYPHILIS. 

frequent  urination,  tenesmus  and  pain,  hsematuria,  and,  sooner  or 
later,  cystitis.  If  from  their  shape  they  exert  constant  pressure  in 
one  portion  of  the  bladder,  ulceration  and  perforation  take  place, 
with  either  the  formation  of  a  limited  abscess  opening  externally  or 
into  one  of  the  neighboring  viscera,  or  diffuse  cellulitis. 

Unless  the  body  is  expelled  shortly  after  it  is  introduced,  or  is  of 
such  a  nature  as  to  be  slowly  disintegrated,  there  is  no  tendency 
towards  spontaneous  evacuation  through  the  urethra.  It  soon  be- 
comes incrusted  with  urinary  salts  and  grows  progressively  larger. 

Diagnosis. — There  is  nothing  in  the  symptomatology  of  a  foreign 
body  to  distinguish  it  from  stone.  Frequently  careful  questioning 
win  ehcit  a  history  of  a  catheter  having  been  broken  in  the  bladder, 
or  of  a  body  which  has  been  introduced  into  the  urethra  having  dis- 
appeared, or  of  a  traumatism,  such  as  gunshot  wound  in  the  vesical 
region.  In  the  absence  of  such  history,  the  diagnosis  is  sometimes 
possible  after  exploration  with  a  vesical  sound  and  bimanual  pal- 
pation. Thus  could  be  felt  a  portion  of  umbrella  rib  or  slate-pencil, 
for  instance.  The  most  reliable  means  of  diagnosis  is  cystoscopic 
examination.  This  will  determine  the  shape,  nature,  and  position  of 
the  foreign  body,  and  will  enable  the  surgeon  to  select  the  safest  and 
most  efficient  methods  of  removing  it  from  the  bladder. 

When  first  inserted,  foreign  bodies  are  comparatively  easy  to  ex- 
tract, since  there  is  then  no  cystitis  and  little  incrustation  has  taken 
place.  These  cases,  however,  rarely  present  themselves  for  treat- 
ment until  cystitis  has  reached  such  a  stage  as  to  cause  almost  un- 
bearable suffering.  The  body  is  then  thickly  crusted  with  urinary 
salts. 

Treatment.— If  the  history  of  the  case  indicates  or  if  cystoscopic 
examination  shows  that  the  bladder  contains  a  portion  of  a  catheter, 
it  is  permissible  to  attempt  first  to  free  it  of  its  incrustation  by  the 
gentle  use  of  a  lithotrite,  and  afterwards  to  grasp  it  in  the  jaws  of  this 
instrument  and  remove  it.  If  possible,  one  end  should  be  seized. 
To  accomplish  this  the  catheter  must  be  grasped  repeatedly  in  various 
positions,  and  only  very  gentle  traction  must  be  exerted  when  the 
attempt  is  made  to  extract  it.  If  properly  grasped,  it  will  come  with- 
out force.  If  caught  in  the  middle  and  not  crusted,  even  though 
doubled,  it  may  sometimes  be  drawn  out  without  injuring  the  urethra. 
If  this  requires  the  least  force,  the  attempt  to  deliver  it  through  the 
urethra  should  be  abandoned. 

Mercier  has  devised  a  special  instrument  for  withdrawing  pieces 
of  catheter.  It  consists  of  two  blades  like  those  of  a  lithotrite.  The 
male  blade  terminates  in  a  hook  with  the  point  directed  downward. 


Fig.  loO. 


1- 


'  ^1/ 


Myxosarcoma.    (Albarran.) 


TUMOKS   OF    THE    BLADDEE.  435 

When  closed  this  hook  shps  into  a  fenestration  in  the  female  blade 
and  the  instrument  presents  a  smooth  rounded  end.  The  catheter, 
being  grasped  transversely,  is  doubled  up  and  drawn  through  the 
urethra. 

Foreign  bodies,  such  as  seeds,  shot,  and  pieces  of  twigs  or  leaves, 
may  be  removed  by  the  tube  and  evacuator  employed  in  litholapaxy. 
If  the  body  is  of  such  shape  or  size  that  it  cannot  be  taken  out 
through  the  urethra,  cystotomy  is  indicated.  Before  the  advent  of 
cystitis,  either  the  suprapubic  or  the  perineal  route  may  be  chosen. 
If  the  foreign  body  is  of  large  size  or  irregular  in  shape,  or  both,  the 
former  route  is  to  be  preferred.  As  soon  as  the  body  is  removed  the 
bladder-wound  should  be  sutured  with  catgut.  Stitches  for  closing 
the  parietal  incision  should  be  introduced  but  not  tied  down,  the 
wound  being  allowed  to  remain  open  for  three  days.  If  the  blad- 
der-suture still  holds  and  the  parietal  incision  is  sterile,  it  is  then 
closed.  Permanent  catheterization  is  desirable  in  these  cases,  though 
not  absolutely  necessary. 

When  the  bladder  is  infected,  or  if  the  foreign  body  is  of  such  size 
that  it  may  be  readily  removed  through  a  comparatively  small  open- 
ing, the  perineal  incision  is  the  safest.  The  after-treatment  is  that 
applicable  to  perineal  urethrotomy. 

In  women  the  greater  distensibility  of  the  urethra  makes  the 
extraction  of  foreign  bodies  much  easier.  Probably  hair-pins  are 
more   frequently  found   than   any  other   foreign   body.      A  special 

Fig.  158. 


Hook  for  the  extraction  of  hair-pins  from  the  female  bladder. 

instrument  is  used  by  French  surgeons  for  their  extraction.     (See 
Fig.  158.) 

TUMORS   OF   THE   BLADDER. 

Tumors  of  the  bladder  may  be  benign  or  mahgnant. 

Benign  tumors  are  the  papillomas,  the  adenomas,  the  fibromas, 
the  myxomas,  and  cysts. 

The  malignant  growths  include  carcinomas,  sarcomas,  and  mixed 
tumors,  except  the  fibromyomas.  Carcinomas  may  be  squamous  or 
glandular.  The  sarcomas  may  be  round-celled,  spindle-celled,  mel- 
anotic, or  mixed,  as  fibrosarcoma,  lymphosarcoma,  and  myxosarcoma. 
(Fig.  159.) 

Of  all  bladder-growths,  more  than  half  are  malignant,  carcinoma 
being  found  more  frequently  than  all  other  bladder-tumors  combined. 


486  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

Of  benign  growths,  papilloma  is  commonest.  Next  in  order  comes 
the  myxoma,  or  bladder  polyp,  adenoma  and  fibroma  are  rare. 

The  seat  of  bladder-tumors  is  usually  about  the  base,  in  the  region 
of  the  trigonum.  Exceptionally,  when  single,  these  growths  are  found 
involving  the  upper  two-thirds  of  the  bladder-walls.  The  mode  of 
attachment  of  the  tumor  to  the  bladder-wall  varies  in  different  cases. 
Sometimes  it  is  attached  by  a  long  slender  pedicle ;  or  the  pedicle 
may  be  broad,  and  there  may  be  infiltration  of  the  surrounding 
bladder-tissues ;  or  there  may  be  no  pedicle ;  or  the  entire  thickness 
of  the  bladder  may  be  involved,  the  infiltration  extending  beyond 
the  area  apparently  diseased.  Men  are  more  frequently  affected  with 
bladder-tumor  than  are  women.  The  tumors  may  develop  at  any 
£^e,  but  are  commonest  between  the  fortieth  and  the  sixtieth  year. 

The  great  frequency  of  bladder-tumors  in  anilin  workers  has  been 
pointed  out  by  Rehn,  twenty-one  cases  having  come  under  his  observa- 
tion since  1895.  Of  these,  three  were  benign  and  eighteen  malignant. 
The  patients  had  been  employed  in  a  factory  from  five  to  twenty- 
nine  years. 

Albarran  states  that  vesical  tumors  are  multiple  in  twenty-five  per 
cent,  of  cases.  Small,  single,  well-pedicled  tumors  are  likely  to  be 
benign  ;  large,  infiltrating,  sessile  tumors  are  commonly  malignant. 

Papilloma. — Papillary  tumors  are  multiple  in  about  forty  per 
cent,  of  all  cases.  (Fenwick.)  They  may  be  pedunculated  or 
sessile  and  vary  from  the  size  of  a  pea  to  that  of  an  orange.  They 
may  form  a  villous  surface,  made  up  of  closely  grouped  fine  papillae 
springing  from  the  mucous  membrane,  or  may  appear  in  the  form 
of  a  cauliflower  growth,  each  of  the  papillae  sending  out  offshoots ; 
in  the  latter  case  they  usually  rise  from  a  comparatively  small  stalk. 
It  must  be  borne  in  mind  that  all  tumors  of  the  bladder  may  be 
covered  by  a  villous  surface.  In  the  true  papillomata,  however,  the 
tumor  is  composed  entirely  of  papillae.  Each  papilla  is  made  up 
of  a  central  capillary  loop,  together  with  a  stroma  of  delicate  fibrous 
tissue,  covered  with  layers  of  cylindrical  epithelium  corresponding  in 
type  with  the  normal  vesical  epithelial  cells.  These  papillae  are 
planted  upon  a  fibro-muscular  base,  and  the  whole  mass  may  be  ses- 
sile, covering  a  comparatively  l^rge  area,  or  may  be  pedunculated,  the 
stem  sometimes  being  half  an  inch  in  diameter.  In  some  cases  papil- 
lomata form  compact  masses  with  villi  of  only  moderate  length. 

Certain  transitional  forms  are  described  in  which  the  histological 
structure  of  the  cells  suggests  that  these  tumors  may  be  transformed 
into  epitheliomata.  Villous  tumors  are  prone  to  bleed  from  partial 
strangulation  of  their  blood-supply  incident  to  muscular  contraction, 


TUMORS   OF   THE    BLADDEE.  437 

and  from  the  fact  that  the  dehcate,  loosely  floating  papillae  are  likely 
to  become  detached.     These  may  be  encrusted  with  urinary  salts. 

Clado  calls  attention  to  the  fact  that  papilloma,  though  classed 
with  the  benign  tumors  histologically,  often  returns  after  removal, 
presenting  then  the  features  of  an  epithelioma. 

Myxoma. — This  tumor  is  much  rarer  than  papilloma.  It  is  most 
frequently  encountered  in  childhood,  and  is  probably  in  some  cases 
congenital.  The  myxomata  are  often  multiple  and  pedunculated, 
and  are  much  like  similar  tumors  found  in  the  nose.  Their  stroma 
is  made  up  of  fibrous  and  mucous  tissue  well  vascularized.  They  are 
hard  or  soft  in  accordance  with  the  preponderance  of  the  mucous  or 
of  the  fibrous  tissue. 

When  multiple,  several  tumors  may  grow  from  a  single  pedicle ; 
this,  by  elongating,  may  allow  the  tumors  to  slip  through  the  female 
urethra  and  appear  at  the  meatus.  The  mucous  membrane  about  the 
attachment  of  the  pedicle  is  not  infiltrated.  These  tumors  may  recur 
even  after  a  seemingly  thorough  removal. 

Fibroma. — Tumors  of  this  variety  in  the  bladder  are  excessively 
rare.  They  resemble  in  structure  fibromata  formed  elsewhere  in  the 
body,  and  are  generally  sessile ;  they  grow  from  the  muscular  coat 
of  the  bladder,  and  are  covered  with  unaltered  mucous  membrane  or 
vilh.     They  invariably  occur  in  adults. 

Myoma. — Myomata  of  the  bladder  were  supposed  by  Virchow  to 
be  merely  prostatic  outgrowths,  but  Belfield  has  demonstrated  that 
there  may  be  myomata  of  the  bladder  pure  and  simple.  They  are 
seldom  pedunculated,  but  are  protruded  from  the  muscular  coat, 
often  appearing  on  the  outside  of  the  organ  as  well  as  in  the  interior. 
They  sometimes  attain  a  large  growth,  sufficient  to  be  mistaken  for  a 
uterine  fibroma,  and  are  extremely  vascular. 

Sarcoma. — Tuffier  quotes  Fenwick,  who  has  collected  fifty  cases 
of  vesical  sarcoma,  as  saying  that  in  children  these  growths  are  often 
multiple,  sessile  or  subsessile,  generally  polypoid  in  form  ;  in  the 
adult  they  are  more  often  simple  than  multiple,  and  are  peduncu- 
lated in  only  ten  per  cent,  of  cases.  In  thirty-four  and  a  half  per 
cent,  of  cases  they  are  of  the  round-celled  variety,  and  in  almost 
seventeen  per  cent,  spindle-celled.  They  attain  a  considerable  size, 
sometimes  that  of  a  foetal  head.  They  are  generally  composed  of 
purely  sarcomatous  elements,  yet  villous  papilloma  degenerating  into 
sarcoma  has  been  observed.  Sarcomata  are  usually  multiple.  They 
commonly  grow  from  the  neighborhood  of  the  ureteral  orifices,  or 
from  the  mucous  membrane  lying  between  these  openings.  In 
women  infiltration  frequently  extends  along  the  urethra.     From  its 


488  GENITO-UKINART   DISEASES   AND   SYPHILIS. 

rapid  growth,  sarcoma  is  likely  to  pass  beyond  the  limits  of  the 
bladder,  invading  the  pericystic  tissues  and  finally  the  bones  of  the 
pelvis. 

A  few  cases  of  angioma,  enchondroma,  and  lymphadenoma  have 
been  noted. 

Carcinoma. — This  may  appear  in  the  form  of  squamous  or  tubular 
(lobulated)  epithelioma  or  alveolar  cancer  (carcinomatous  epithelioma). 
(Figs.  160,  161.) 

Vesical  cancer  is  usually  sessile,  involves  the  whole  thickness  of 
the  bladder-wall,  and  presents  an  uneven,  often  ulcerating,  surface ; 
it  is  hard  on  palpation,  is  surrounded  by  peripheral  induration,  and 
is  frequently  multiple.  The  growth  is  extremely  slow.  Extensive 
ulceration  is  rare  ;  metastasis  is  also  sometimes  entirely  wanting. 
The  affection  occurs  most  frequently  in  men,  and  between  the  fiftieth 
and  the  sixtieth  year. 

At  times  the  growth  is  pedunculated,  suggesting  the  appearance 
of  papilloma. 

On  intravesical  examination  these  growths  are  found  to  vary 
greatly  in  appearance.  They  may  form  irregularly  projecting  masses 
covered  with  normal  mucous  membrane,  or  they  may  appear  as  com- 
paratively flat  areas  of  induration,  the  surface  of  which  may  be  smooth 
or  ulcerated.  In  some  cases  there  is  bulk  sufficient  almost  entirely  to 
fill  the  bladder ;  very  frequently  the  surface  is  covered  by  a  papil- 
lary growth.  Infiltration  and  induration  are  the  most  characteristic 
features. 

When  by  rectal  examination  a  hardening  of  the  bladder-wall  can 
be  felt,  this  is  almost  pathognomonic  of  cancer. 

Although  extension  of  the  disease  to  the  iliac  and  abdominal 
glands  and  thence  to  the  abdominal  viscera  occurs,  extension  to 
neighboring  organs  appears  to  be  rare.  Watson  quotes  Barling  to 
the  effect  that  in  only  three  out  of  fifteen  cases  of  carcinoma  of  the 
bladder  did  extension  to  neighboring  organs  occur ;  and  in  nine,  in 
the  same  series  of  cases,  secondary  deposits  were  found  in  other 
organs.  Of  forty-nine  cases,  thirty-three  had,  as  secondary  changes, 
hydronephrosis  or  pyonephrosis,  or  both. 

Watson  adds,  "  The  remarkable  tendency  of  carcinoma  of  the 
bladder  to  remain  localized  for  very  long  periods  has  been  commented 
on  by  various  writers,  and  is  generally  explained  by  the  absence,  ac- 
cording to  some  investigators,  or  by  the  meagreness,  according  to 
others,  of  the  supply  of  lymphatic  channels  in  the  bladder.  Barling 
quotes  Hoggan  with  reference  to  this  matter  as  follows :  '  There  is 
but  one  set  of  lymphatic  vessels  over  the  bladder,  except  at  the  tri- 


TUMORS   OF   THE   BLADDER.  489 

gone.  This  single  layer  commences  on  the  deep  or  mucous  surface 
of  the  muscular  coat,  beginning  as  loops  or  chains  around  the  smaller 
arteries  or  veins  within  that  coat,  as  though  destined  to  absorb  their 
exudations  rather  than  those  of  the  mucous  membrane.  These 
lymphatics  concentrate  into  two  main  sets,  one  going  back  to  the 
neck  of  the  bladder,  the  other  towards  the  urachus.'  These  are  said 
by  the  text-books  to  empty  into  the  internal  ihac  glands,  but  Hoggan 
says  this  is  incorrect.  At  the  trigone  there  is  a  second  set  of  purely 
collecting  lymphatics  arising  in  the  mucous  membrane  and  connecting 
with  the  deeper  set.  This  lack  of  direct  connection  of  the  larger 
portion  of  the  lymphatic  channels  with  the  mucous  membrane  ex- 
plains the  failure  of  the  neighboring  glands  to  become  involved  in 
some  cases  or  their  tardy  infection  in  others.  This  also  explains  the 
extraordinarily  long  course  of  the  disease  that  has  been  noted." 

Symptoms. — The  benign  bladder-tumor  may  exist  for  years  and 
excite  no  symptoms. 

Usually  hemorrhage  is  a  symptom  which  first  suggests  the  possi- 
bility of  a  bladder-growth.  This  hemorrhage  occurs  without  apparent 
cause,  its  onset  is  sudden,  and  it  disappears  as  quickly  as  it  comes. 
If  the  bleeding  is  copious,  if  the  last  urine  passed  contains  more  blood 
than  that  first  evacuated,  if  the  blood  is  bright  red  in  color,  if  clots 
are  passed,  and  if  gentle  instrumentation  occasions  free  hemorrhage, 
all  the  characteristic  features  of  bleeding  from  bladder-tumor  will  be 
present. 

This  bleeding  may  last  a  day,  or  may  continue  for  weeks,  may  be 
so  slight  as  to  excite  no  constitutional  symptoms,  or  may  be  severe. 
Exceptionally,  as  a  result  of  intravesical  bleeding,  dense  clots  so 
obstruct  urination  that  immediate  operation  is  necessary.  Frequent 
recurrences  of  the  bleeding  may  exhaust  the  patient,  and  may  finally 
occasion  death.  It  must  be  borne  in  mind  that  the  amount  of  bleeding 
is  by  no  means  commensurate  with  the  size  of  the  tumor.  At  times, 
in  place  of  heematuria,  or  associated  with  it,  there  is  what  Ultzmann 
calls  fibrinuria, — that  is,  in  place  of  pure  blood  the  albuminous  con- 
stituents of  this  fluid  are  exuded  through  the  distended  vessels  in  the 
region  of  the  growth.     The  urine  when  passed  coagulates. 

Pain  usually  is  not  severe,  except  when  there  is  accompanying 
cystitis.  It  is  especially  marked  when  the  tumor  is  placed  in  the 
region  of  the  vesical  neck  and  is  reflected  to  the  hypogastric  region, 
the  anus,  the  testicle,  the  penis,  and  down  the  thighs.  It  is  most 
marked  on  the  completion  of  urination  and  when  the  bladder  is  in- 
vaded by  a  mahgnant  growth.     Benign  tumors  often  cause  no  pain. 

Frequent  urination  is  not  a  constant  symptom.     When  noted  it  is 


490  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

not  aggravated  by  exercise,  and  is  not  more  marked  at  night.  Pain 
and  frequent  urination  are  constant  and  distressing  symptoms  when 
the  bladder  has  become  infected ;  they  are  then  due  to  the  cystitis 
rather  than  to  the  tumor. 

The  -passage  of  fragments  of  the  tumor  is  the  only  absolutely  con- 
clusive sign  of  bladder-tumor,  aside  from  direct  examination.  A 
microscopical  examination  is  necessary  to  determine  the  nature  of 
the  fragments  passed,  since  coagulated  fibrin  or  blood-clot  may 
readily  be  mistaken  for  a  new  growth  when  examined  macroscopi- 
cally. 

Diagnosis. — This  is  founded  on  the  sudden,  apparently  causeless 
free  bleedings  recurring  with  increasing  frequency,  the  passage  of 
tumor-fragments,  examination  with  the  cystoscope  (see  Cystoscopy), 
combined  rectal  and  suprapubic  palpation  in  the  case  of  malignant 
growths  (see  p.  445),  and  exploratory  perineal  or  suprapubic  cystot- 
omy. Myxomata  and  non-infiltrating.growths  cannot  be  detected  by 
palpation. 

The  passage  of  irregularly  shaped  clots,  superabundance  of  epi- 
thelial cells,  absence  of  fragmentation  in  the  blood-corpuscles,  ab- 
sence of  kidney  albumen,  and  the  presence  of  absorption  bands  of 
oxyhEemoglobin  on  spectroscopic  examination,  would  indicate  at  least 
the  vesical  origin  of  the  bleeding. 

The  successive  appearance  of  single  symptoms  strongly  points  to 
vesical  tumor ;  the  immediate  association  of  several  symptoms  is  the 
rule  in  cystitis.  In  the  latter  the  appearance  of  pus  is  never  long 
delayed  ;  in  tumors  it  is  often  delayed.  In  tumors  that  infiltrate  the 
bladder-wall,  in  contradistinction  to  pedunculated  neoplasms,  hemor- 
rhage may  be  a  late  symptom,  while,  on  the  other  hand,  the  irrita- 
tion of  the  muscular  wall  induces  frequent  urination  at  an  earlier 
period  than  in  tumors  with  a  pedicle.  Haematuria,  intermittent  or 
profuse  and  lasting  a  long  time,  without  other  symptoms,  is  always 
suggestive  of  vesical  tumor  rather  than  of  cystitis.  There  may  be 
little  hemorrhage  in  some  extensive  tumors  of  the  bladder,  but  every 
neoplasm  of  the  bladder  must  at  some  time  be  associated  with  more 
or  less  bleeding,  usually  more  than  in  cystitis.  In  any  case  in  which 
doubt  exists,  if  the  usual  treatment  for  cystitis  is  not  followed  by 
benefit,  a  tumor  is  probably  present. 

A  bladder  which  contains  a  tumor  is  peculiarly  susceptible  to  infec- 
tion, and,  as  the  supervention  of  cystitis  greatly  increases  the  suffering 
of  the  patient  and  adds  materially  to  the  risk  of  surgical  intervention,  it 
is  best  in  suspected  cases  to  pass  no  instrument  into  the  bladder  until 
all  preparations  are  made  to  operate  at  once  in  case  a  tumor  is  found. 


TUMOKS   OF   THE    BLADDER.  491 

Prog7iosis.—ln  even  benign  tumors  the  outlook  of  a  case  allowed 
to  run  its  course  is  unfavorable.  Very  exceptionally  individual  poly- 
poid growths  are  discharged  spontaneously.  As  a  rule,  the  growth 
is  progressive.  Freyer  mentions  a  case  of  papilloma  existing  eighteen 
years. 

From  mechanical  action  a  large  tumor  of  the  bladder  may  cause 
displacement  of  neighboring  organs,  pressure  upon  the  rectum,  or 
partial  or  complete  obliteration  of  the  ureters  or  the  urethra.  Cystitis 
is  a  constant  accompaniment,  and  is  usually  severe.  The  common 
cause  is  uncleanly  catheterization.  It  is  sometimes  complicated  by  a 
pericystitis,  causing  fibro-adipose  deposits,  which  limit  the  movements 
of  the  bladder. 

The  patient  ultimately  perishes,  either  from  exhaustion  incident 
to  hemorrhage  or  from  ascending  pyelonephritis.  The  course  of 
these  cases  is  often  extremely  slow. 

When  the  tumor  is  thoroughly  removed  the  prognosis  in  benign 
cases  is  good,  though  recurrence  may  take  place.  Even  in  malignant 
growths  a  thorough  removal  in  the  early  stages  may  accomplish  radi- 
cal cure. 

Treatment. — It  is  of  cardinal  importance  in  cases  of  suspected 
bladder-tumor  to  avoid  infecting  the  vesical  mucosa  when  such  in- 
fection has  not  already  taken  place.  The  diagnosis  having  been  es- 
tablished, there  is  but  one  treatment  to  be  seriously  considered, — 
complete  removal  of  the  growth. 

The  palliative  treatment  of  tumors  of  the  bladder  is  confined  to 
checking  bleeding  and  reheving  pain.  This  treatment  may  be  re- 
quired because  of  reluctance  on  the  part  of  the  patient  to  consent 
to  operation ;  more  frequently  because  by  the  time  a  positive  diag- 
nosis of  tumor  is  made  infiltration  has  already  extended  wide  of  the 
bladder,  and  a  radical  operation  is  no  longer  possible.  The  treat- 
ment of  haematuria  in  general  is  that  applicable  to  the  relief  of 
vesical  congestion.  Direct  local  treatment  may  be  conducted  by  hot 
injections  of  alum  four  drachms  to  the  pint,  hydrastis  two  ounces  to 
the  pint,  or  acetanilid  five  per  cent,  solution,  or  adrenalin  solution 
1  to  5000.  When  clots  are  present  and  produce  retention,  they  should 
be  aspirated  through  a  catheter  or  litholapaxy  evacuating  tube.  If 
bleeding  persists  in  spite  of  injections,  or  if  these  produce  great  pain 
and  seem  to  increase  hemorrhage,  permanent  catheterization  is  indi- 
cated. If  this  is  unsuccessful  because  the  catheter  becomes  blocked 
by  clots,  perineal  drainage,  with  the  insertion  of  a  large  tube,  is  advis- 
able. Through  this  tube  the  bladder  can  be  abundantly  flushed  with 
comparatively  strong  astringent  injections.     Should  these  means  fail 


492  GEXITO-URIXART    DISEASES   AXD    SYPHILIS. 

to  arrest  the  bleeding,  and  should  life  be  immediately  threatened  by 
its  contmuance,  the  bladder  should  be  opened  above  the  pubis,  the 
edges  of  the  vesical  wound  sutured  to  the  parietal  incision,  and,  drain- 
age-tubes having  been  carried  to  the  region  of  the  ureters,  the  bladder 
should  be  firmly  packed  with  iodoform  gauze. 

Pain  may  be  quieted  by  instillations  of  cocaine.  Usually  mor- 
phine hjTDodermically  will  be  required  for  its  relief.  Cystitis  or  re- 
tention should  be  treated  in  accordance  Avith  the  directions  already 
given. 

The  use  of  astringents  by  tlie  mouth  is  sometimes  ser\iceable  in 
lessening  hemorrhage  ;  hydrastis,  ergotin,  and  gallic  acid  may  possibly 
exert  some  local  influence. 

Operative  Treatment. — The  method  of  reaching  the  tumor  will 
depend  upon  its  size,  location,  and  nature.  It  may  be  approached 
through  the  urethra,  through  a  median  perineal  opening  into  the 
membranous  urethra,  or  through  a  suprapubic  opening. 

Removal  through  the  urethra  has  been  successfully  accomplished 
in  the  case  of  small  pedunculated  individual  polypoid  growths.  It  is 
micertain  and  not  to  be  commended.  The  instrument  commonly 
employed  is  the  lithotrite,  the  location  of  the  tumor  having  been  pre- 
viously determined  by  a  cystoscopic  examination. 

The  perineal  route,  highly  commended  by  Thompson,  and  pri- 
marily employed  by  him  for  diagnostic  purposes,  is  serviceable  for 
the  removal  of  polypoid  growths,  especially  when  these  are  placed 
near  the  vesical  orifice,  though  when  the  perineum  is  not  unusually 
deep  and  the  bladder  is  not  pushed  up  by  an  enlarged  prostate,  a 
finger  passed  through  this  opening  into  the  bladder  and  aided  by 
pressure  above  the  pubis  with  the  other  hand  can  make  an  examina- 
tion of  every  portion  of  the  vesical  mucous  membrane.  The  advan- 
tages of  this  route  are  its  much  lower  mortality  and  the  thoroughness 
of  the  drainage  which  it  provides.  Its  disadvantages  depend  upon 
the  fact  that  the  surgeon  is  forced  to  operate  through  a  small  openings 
— i.e..  the  undivided  neck  of  the  bladder, — and  that  he  must  depend 
entirely  upon  the  sense  of  touch. 

For  the  seizure  and  removal  of  growths  by  this  route  polypus 
forceps  with  serrated  blades  are  employed,  straight  and  curved  (Fig, 
162);  also  forceps  with  cutting  edges  are  used  when  the  growths  are 
more  dense  and  less  distinctly  pedunculated.  The  patterns  furnished 
by  Thompson  are  the  best  (Fig.  162.)  The  growth  is  removed  by 
introducing  the  forceps  into  the  bladder,  opening  them  widely,  and 
then  closing  them  as  near  the  region  of  the  base  of  the  polyj)  as  can 
be  calculated.     By  firmly  grasping  the  polj^p  it  may  be  removed  by 


TUMORS   OF    THE    BLADDER. 


49^ 


the  forceps  aided  by  twisting ;  forcible  traction  should  be  avoided, 
and  Thompson  especially  cautions  against  exerting  suprapubic  press- 
ure while  the  forceps  are  introduced  in  search  of  polypi,  since  thus 
a  fold  of  the  bladder  may  be  grasped  and  crushed,  resulting  possibly 
in  perforation  and  fatal  peritonitis.  As  each  portion  of  the  growth 
is  removed  the  fmger  should  be  inserted,  to  determine  exactly  how 
much  has  been  accomplished.  Sessile  growths,  especially  if  extensive, 
are,  of  course,  not  amenable  to  this  operation. 

For  the  performance  of  suprapubic  cystotomy  for  the  removal  of 
vesical  tumors,  the  surgeon  should  be  provided  with  a  catheter  of  me- 
dium calibre  which  can  be  introduced  into  the  bladder  without  diffi- 
culty, a  four-ounce  syringe,  the  nozzle  of  which  fits  accurately  into 

Fig.  162. 


Thompson's  forceps  for  removing  vesical  tumors. 


the  catheter,  two  broad  retractors,  an  electric  light,  two  glass  vaginal 
specula,  special  crushing  or  avulsion  forceps,  a  wire  ecraseur,  the 
Paquelin  or  galvano-cautery,  and  the  ordinary  operating  instruments, 
— i.e.,  knives,  scissors,  haemostatic  forceps,  tenacula,  straight  and 
curved  needles,  a  needle-holder,  and  a  grooved  director. 


494  GENITO-URINARY    DISEASES   AND    SYPHILIS. 

The  incision  is  the  same  as  that  already  described  in  treating  of 
suprapubic  cystotomy  for  the  removal  of  large  calculi. 

It  is  at  this  stage  of  the  operation  that  the  Trendelenburg  position 
becomes  useful,  the  rectal  bag  being  removed  if  this  has  been  used. 
With  an  irrigator  and  sponges  the  bladder  is  cleansed  of  blood-clots 
and  dried.  The  electric  light  is  then  turned  on,  and  the  interior  of 
the  bladder  is  inspected.  This  portion  of  the  examination  may  be 
greatly  facilitated  by  the  use  of  a  glass  speculum,  as  suggested  by 
Fenwick,  The  instrument  selected  is  from  an  inch  to  an  inch  and 
a  half  in  diameter ;  it  is  passed  into  the  bladder,  and  is  used  on  the 
principle  of  a  caisson, — that  is,  its  end  is  held  in  contact  with  the 
mucous  membrane,  and  the  portion  thus  included  is  thoroughly  dried 
by  sponging.  This  portion  can  then  be  inspected,  since  no  further 
obscuration  with  blood  or  urine  is  possible  until  the  speculum  is  lifted 
from  its  place,  unless  it  includes  the  bleeding  area  or  the  orifice  of 
the  ureter. 

When  the  bladder  is  small  and  not  distensible,  as  is  the  case  after 
prolonged  interstitial  cystitis,  or  when  from  the  size  of  the  tumor  it  is 
obvious  that  more  room  will  be  required  than  is  given  by  the  ordinary 
vertical  incision,  the  transverse  cut  may  be  made.  (Trendelenburg.) 
This  is  four  inches  long,  slightly  convex  downward,  and  is  carried 
along  the  upper  border  of  the  symphysis.  The  attachments  of  the 
recti  muscles  are  divided,  and  the  prevesical  space  and  the  bladder 
are  both  opened  by  a  transverse  cut.  This  gives  a  larger  vesical 
wound  without  endangering  the  peritoneum,  and  consequently  makes 
intravesical  manipulations  easier.  The  bladder-wound,  which  should 
be  almost  as  large  as  that  of  the  parietes,  should  be  temporarily 
sutured  to  the  latter. 

The  incision  of  choice  for  bladder-tumor  is  either  the  vertical  or 
the  transverse.  The  latter  gives  a  wider  exposure,  is  easier  of  per- 
formance, and  is  less  likely  to  be  complicated  by  wound  of  the  peri- 
toneum. It  is  open  to  the  objection  that  it  materially  weakens  the 
belly-wall  and  is  liable  to  be  followed  by  hernia. 

Pedunculated  growths  so  placed  that  the  bases  cannot  be  well 
excised  may  be  removed  by  Watson's  galvano-cautery  scissors  or  by 
the  ecraseur,  in  the  latter  case  their  pedicles  being  destroyed  by  the 
actual  cautery.  The  bases  of  extensive  sessile  growths  which  have 
been  removed  by  the  knife  or  the  curette  may  also  be  cauterized. 

When  the  tumor  infiltrates  the  whole  thickness  'of  that  portion 
of  the  bladder-wall  which  is  covered  by  peritoneum,  this  investment 
should  be  dissected  up  and  partial  resection  of  the  bladder  prac- 
tised.    When  the  peritoneum  also  is  involved,  this  must  be  included 


TUMORS   OF    THE    BLADDEE.  495 

in  the  resect:on.  The  tumor  having  been  pulled  forcibly  outward, 
a  clamp  is  applied  tightly  to  the  inverted  bladder-walls  entirely  be- 
yond the  growth,  thus  forming  of  these  walls  an  artificial  pedicle. 
The  peritoneal  cavity  is  then  opened,  and  the  surfaces  of  the  vesical 
peritoneum  which  are  apposed  by  the  inversion  and  clamping  of  the 
bladder  are  secured  by  a  double  row  of  catgut  sutures.  The  peri- 
toneal cavity  is  closed,  and  the  tumor  is  removed  by  cutting  through 
the  whole  thickness  of  the  inverted  bladder-walls.  Vessels  which 
bleed  freely  may  be  ligated ;  usually  a  continuous  catgut  suture  so 
applied  that  the  cut  surfaces  are  accurately  apposed  will  check  hem- 
orrhage. 

When  the  tumor  infiltrates  the  base  of  the  bladder  about  the  ure- 
teral orifices,  its  thorough  removal  is  often  impossible  without  division 
of  the  ureters.  This  is  not,  however,  an  absolute  contra-indication 
to  an  attempt  at  radical  cure.  In  case  of  wide-spread  disease  the 
entire  bladder  has  been  resected.  A  total  resection  reported  by  Pawlik 
is  most  noteworthy,  since  the  result  was  entirely  satisfactory.  The 
ureters  were  freed  from  their  bladder  attachments  and  stitched  into 
the  vaginal  wound ;  later,  through  a  suprapubic  incision,  the  blad- 
der was  dissected  free  of  its  peritoneal  and  fibrous  attachments  and 
was  cut  away  from  the  urethra.  Catheters  were  passed  through 
the  urethra  into  the  ureters,  and  the  vagina  was  closed  externally.  A 
fistula  remained,  which,  after  several  operations,  became  so  small 
that  urine  escaped  only  when  the  patient  was  standing.  The  artificial 
bladder  was  able  to  retain  twelve  ounces  of  urine.  Pawlik  made  a 
final  report  of  this  case  two  years  after  operation. 

When  the  tumor  is  limited  to  the  ureteral  region  and  there  is 
reason  to  believe  that  its  thorough  removal  may  be  followed  by  a 
permanent  cure,  resection  is  indicated  even  though  the  ureter  is 
necessarily  divided. 

Clado,  after  a  careful  consideration  of  the  methods  of  disposing 
of  the  ureter  when  malignant  tumor  involves  the  bladder  in  the 
region  of  the  ureteral  orifice,  comes  to  the  following  conclusions  : 
Leaving  the  ureter  open  in  the  wound  after  extirpation  of  a  neoplasm 
is  extremely  dangerous.  Implantation  into  the  rectum  is  almost 
invariably  fatal.  Implantation  into  the  colon  is  more  successful, 
having  thus  far  given  four  successes.  Implantation  into  the  parietal 
wound  is  sometimes  a  matter  of  necessity.  Implantation  into  the 
vesical  cavity  and  anastomosis  with  the  ureter  of  the  other  side  are 
the  two  operations  which  give  greatest  promise  of  definite  recovery. 

Albarran  proposes  ligature  of  the  ureter  and  consequent  destruc- 
tion of  the  secreting  substance  of  the  kidney  of  that  side,  holding 


496  GENITO-UKIlSrAPvY   DISEASES   AND    SYPHILIS. 

that  the  danger  of  this  operation  is  much  less  than  that  of  ne- 
phrectomy. He  thus  summarizes  the  general  treatment  of  malignant 
tumors  of  the  bladder :  The  patient  should  be  placed  in  the  Tren- 
delenburg position  and  the  neoplasm  subjected  to  an  examination. 
If  the  tumor  is  sessile,  if  no  enlarged  gangha  are  found,  and  if  the 
patient  is  in  good  condition,  resection  of  the  bladder-wall  is  indicated. 
This  resection  is  easily  performed  if  the  tumor  is  placed  above  the 
opening  of  the  ureters,  since  it  is  then  usually  accessible,  enough  room 
being  secured  by  an  incision  through  the  attachments  of  the  recti 
muscles.  When  the  tumor  is  placed  posteriorly  in  a  bladder  which 
is  naturally  deep-seated,  or  about  the  ureteral  orifice,  or  behind  the 
anterior  wall  of  the  bladder  masked  by  the  pubic  symphysis,  partial 
resection  of  the  symphysis  or  symphyseotomy  may  be  required. 

Resection  of  the  tumor  is  easiest  when  it  is  situated  upon  the 
upper  portion  of  the  bladder,  where  the  peritoneum  can  be  readily 
stripped  back.  After  this  stripping,  the  tumor  with  a  portion  of 
the  healthy  bladder- wall  is  cut  away  with  scissors  and  the  wound 
is  sutured.  If  the  tumor  is  placed  above  the  ureters  posteriorly,  it 
may  be  circumscribed  by  an  incision  through  the  mucous  membrane 
and  resected  from  within  outward,  no  effort  then  being  made  to  strip 
the  peritoneum  first.  If  the  tumor  is  placed  about  the  orifice  of 
the  uretei,  the  latter  should  be  catheterized,  should  then  be  exposed 
by  cutting  through  the  lateral  wall  of  the  bladder,  and  should  be  freed 
and  implanted  into  a  healthy  portion  of  the  viscus.  (See  section  on 
Ureters.)  If  this  operation  is  impossible,  the  wound  made  through 
the  bladder-wall  for  the  purpose  of  exposing  the  ureter  should  be 
closed,  and  the  urine  escaping  through  the  ureteral  catheter  should 
be  examined  carefully.  If  this  urine  is  clear,  showing  that  the  kid- 
ney is  not  infected,  the  catheter  should  be  withdrawn,  and  the  ureter 
should  be  ligated  and  divided  below  the  ligature.  If  the  urine  es- 
caping through  the  catheter  is  turbid,  showing  admixture  of  pus,  the 
ureter  should  be  divided  and  fixed  to  the  abdominal  wound.  L. 
Fraenkel  advises  that  when  the  ureter  is  ligated,  the  renal  end  should 
be  brought  out  at  the  skin  incision  and  fastened,  to  provide  for  the 
relief  of  hydronephrosis  which  is  sure  to  follow,  and  is  sometimes 
productive  of  uraemia.  The  distal  divided  end  may  be  cauterized 
and  invaginated.  Whatever  procedure  is  employed  for  the  purpose 
of  giving  more  room,  the  bladder  should  be  closed  completely,  a  per- 
manent catheter  should  be  introduced,  and  the  prevesical  space  should 
be  packed  with  iodoform  gauze.  Total  resection  of  the  bladder  is 
indicated  only  in  the  case  of  multiple  epitheliomata  which  have  not 
yet  extended  beyond  the  muscular  wall. 


TUMORS   OF   THE   BLADDER.  497 

The  tumor  having  been  removed,  and  hemorrhage  having  been 
stopped  by  suture,  Hgature,  cautery,  or  packing,  drainage  is  pro- 
vided for  by  tubes  passing  through  the  suprapubic  opening,  by  the 
permanent  catheter,  or  by  perineal  urethrotomy.  The  bladder- 
wouni^  is  closed  by  interrupted  catgut  sutures,  placed  about  a  quarter 
of  an  inch  apart,  beginning  below  and  passing  upward.  These  sutures 
include  the  whole  thickness  of  the  bladder,  except  the  innermost 
layers  of  the  epithelial  coat,  and  bring  into  accurate  apposition  the  cut 
surfaces  ;  inversion  or  eversion  must  be  carefully  avoided.  The  proper 
placing  of  these  sutures  is  much  facilitated  by  the  loops  placed  in  the 
margins  of  the  bladder-wound  for  the  purpose  of  retracting  it, 

Guyon  sutures  the  bladder  closely  about  his  siphon  drainage-tubes. 
These  are  made  of  rubber,  are  one  and  a  half  feet  long,  and  of 
calibre  1 4  F.  They  are  adherent  to  each  other  for  about  one  inch  at 
the  vesical  end,  and  are  so  curved  that  the  extremity  passes  downward 
and  backward  to  the  most  dependent  part  of  the  bladder.  The  external 
portion  passes  over  the  pubis  downward  between  the  thighs,  and  the 
two  unattached  ends  are  plunged  into  a  urinal  containing  antiseptic 
solution.  Each  of  these  tubes  is  provided  with  an  eye  near  the  end  of 
the  vesical  extremity,  and  each  is  notched  on  its  end.  They  are  placed 
vertically  one  above  the  other,  and  one  usually  proves  the  better  drain. 
Before  closing  the  parietal  wound,  the  fact  that  these  tubes  are  patu- 
lous is  determined  by  injecting  fluid  into  one  of  them ;  this  should 
flow  out  through  the  other,  and  not  through  the  bladder- wound  beside 
the  tubes.  The  external  wound  is  then  closed  by  a  double  row  of 
sutures,  one  buried,  of  catgut,  including  the  muscles  and  deep  fascia, 
the  other,  of  Chinese  silkworm-gut,  including  the  skin  and  its  under- 
lying fascia.  The  prevesical  space  is  drained  by  gauze  packing  car- 
ried through  the  lower  angle  of  the  wound,  which  is  left  open.  The 
siphon  tubes  are  secured  to  the  skin  by  sutures  which  are  loosely 
knotted. 

This  is  the  method  of  treatment  practised  by  Guyon,  and  he 
states  that  drainage  is  so  perfect  that  the  dressing  remains  dry  and 
need  not  be  changed  for  several  days.  The  external  dressing  is 
made  up  of  sterile  iodoform  gauze,  secured  by  an  abdominal  binder 
or  double  spica  of  the  groin.  The  patient  is  placed  on  his  back  in 
bed,  the  free  ends  of  the  siphon  tube  are  placed  in  an  antiseptic 
solution  in  the  urinal,  and  every  three  or  four  hours  the  bladder  is 
gently  washed  out.  The  dressing  is  changed  the  fourth  or  sixth  day, 
the  siphon  drainage-tubes  are  removed,  and  continuous  catheteriza- 
tion is  practised.  The  vesical  opening  is  usually  closed  within  two 
wrecks.     Many  surgeons  advise  an  attempt  at  complete  suture  of  the 

32 


498  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

bladder.  The  rules  formulated  in  considering  the  after-treatment  of 
suprapubic  cystotomy  for  vesical  calculus  are  apphcable  when  this 
operation  is  undertaken  for  tumor.  When  the  bladder  is  healthy, 
the  urine  non-infected,  the  wound  left  after  extirpation  of  the  tumor 
completely  closed  by  suture,  and  the  operation  has  not  been  extensive, 
immediate  vesical  and  parietal  suture  and  permanent  catheterization 
are  indicated.  When  the  bladder  is  infected,  but  the  operation  has 
not  been  extensive,  immediate  vesical  suture,  with  drainage  of  the 
prevesical  space  and  the  insertion  of  a  permanent  catheter  or  of  a 
large  perineal  tube,  is  indicated.  When  operation  has  been  extensive, 
the  suprapubic  drainage  is  advisable.  Neither  the  T  tube  of  Tren- 
delenburg, the  siphon  drainage  of  Cathcart,  capillary  drainage,  nor  any 
other  form  of  drainage  accomplishes  what  Guyon  and  Albarran  claim 
for  their  siphon  tubes. 

Clado  has  collected  twenty-nine  cases  of  partial  cystectomy,  with 
twenty  operative  recoveries  and  nine  deaths,  and  five  cases  of  total 
cystectomy,  with  two  recoveries  (both  in  women)  and  three  deaths 
(all  in  men).  The  mortality  in  cases  of  ligation  of  one  renal  vessel 
or  ureter  is  higher  than  after  nephrectomy,  apparently  due  to  auto- 
nephro-toxins.  After  ligation  there  are  noted  degenerative  changes 
in  the  opposite  kidney,  the  so-called  sympathetic  nephritis.  After 
nephrectomy  these  changes  are  not  observed. 

Extirpation  of  the  Bladder. — Hartley  collected  twenty  three  cases 
of  complete  removal  of  this  organ  for  malignant  disease.  The  total 
recoveries  were  twelve,  giving  a  mortality  of  forty-seven  and  eighty- 
three  one  hundredths  per  cent.  Five  patients  died  during  operation, 
three  of  collapse  afterward,  and  four  a  few  days  later. 

The  ureters  were  implanted  into  the  bowel  in  eleven  cases  with  six 
deaths,  and  into  the  vagina  in  seven  cases  with  one  death  from  shock. 

The  operation  is  indicated  only  in  cases  in  which  complete  removal 
of  the  malignant  disease  is  impossible  by  partial  resection,  and  in 
which  it  is  possible  to  remove  all  the  disease  by  cystectomy.  It  is  con- 
tra-indicated when  the  malignant  disease  has  extended  beyond  the  blad- 
der, at  least  when  more  than  the  prostate  and  seminal  vesicles  are 
involved. 

Preparation  of  the  Patient. — The  bowels  and  bladder  should  be 
thoroughly  emptied  and  cleansed  with  antiseptics.  The  loAver  abdo- 
men, perineum,  and  external  genitalia  are  thoroughly  prepared  accord- 
ing to  the  usual  routine,  and  immediately  before  operation  the  bladder 
is  filled  with  an  antiseptic  solution. 

The  instruments  required  are  three  scalpels,  small  and  large  haamo- 
stat3  in  abundance,  Spencer  Wells  forceps,  tissue  forceps,  catheters, 


TUMOKS   OF    THE    BLADDER. 


499 


four  retractors,  an  electric  light,  a  Paquelin  or  galvano-cautery,  scissors, 
tenacula,  a  blunt  dissector,  straight  and  curved,  round  and  flat  needles, 
heavy  and  fine  silk,  chromicized  catgut,  silkworm  catgut,  volsella 
forceps. 

The  patient  is  placed  in  the  Trendelenburg  posture,  the  bladder 
is  distended,  and  a  vertical  incision  four  or  five  inches  long  is  made  in 
exactly  the  median  line  as  in  suprapubic  cystotomy,  but  extending 
higher.  This  exposes  the  bladder  and  the  reflection  of  peritoneum, 
the  latter  being  pushed  v^^ell  upv^ard.  A  transverse  incision  is  made 
from  the  lower  end  of  the  wound,  dividing  all  the  parietal  structures 


Fig.  163. 


.ffm 


V 


Implantation  of  the  ureter  into  the  bowel. 


to  each  external  inguinal  ring  just  above  the  pubic  bone  and  Poupart's 
ligament.  The  rectangular  flaps  thus  outlined  are  dissected  and 
retracted  upward  and  outward  to  aUow  free  access  to  the  bladder. 
While  moderate  traction  is  made  upward  on  the  lateral  aspects  of  the 
bladder,  the  anterior  wall  is  separated  by  blunt  dissection  from  the 
pubis  down  to  the  vesical  neck,  which  is  exposed,  isolated,  and  clamped 
tightly  with  two  pairs  of  Spencer  Wells  forceps.  The  neck  of  the 
bladder  is  divided  between  the  forceps  and  each  stump  cauterized. 
The  peritoneum  is  carefully  peeled  and  removed  from  the  superior. 


500  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

posterior,  and  lateral  aspects  of  the  bladder  by  blunt  dissection,  pref- 
erably with  the  finger,  avoiding  opening  the  peritoneal  cavity.  The 
inferior  vesical  arteries  and  ureters  are  secured  close  to  the  bladder 
with  large  curved  hsemostats  and  divided  between  the  forceps  en  masse. 
The  ureteral  openings  are  cauterized  at  each  end  and  the  vesical 
arteries  ligated,  after  which  the  base  of  the  bladder  may  be  carefully 
separated  from  its  attachments  and  the  viscus  removed.  The  ureters 
are  brought  out  each  through  a  lumbar  incision  (Watson),  the  stump 
of  the  urethra  ligated,  all  bleeding  stopped,  and  the  deep  wound  packed 
tightly  with  gauze,  the  drainage  being  brought  out  just  over  the  sym- 
physis. Both  transverse  cuts  and  most  of  the  median  incision  may  be 
sutured,  and  the  external  wound  dressed. 

Harris  advises,  especially  if  the  prostate  is  involved,  division  of  the 
urethra  at  the  triangular  ligament  while  traction  is  made  on  the  blad- 
der anteriorly,  and  removing  the  bladder  and  prostate  together,  these 
being  separated  from  the  rectum  while  an  assistant's  finger  is  inserted 
in  the  latter.  He  would  also  endeavor  to  preserve  the  portion  of  the 
bladder-wall  into  which  the  ureters  empty  and  suture  this  as  near  as 
possible  to  the  posterior  portion  of  the  urethra  in  the  hope  that  it  may 
ultimately  regenerate  into  a  serviceable  reservoir. 

Complications  and  Sequelae. — These  are  similar  to  those  described 
under  suprapubic  cystotomy  for  the  removal  of  stone.  Since  an 
operation  for  the  removal  of  tumor  is  prolonged  and  is  often  attended 
by  profuse  hemorrhage,  shock  and  collapse  are  particularly  to  be 
guarded  against.  Should  the  patient  escape  these  dangers,  suppres- 
sion of  urine,  urinary  fever,  or  infection  of  the  kidneys  may  develop. 
The  most  frequent  complication  is,  however,  urinary  infiltration  with 
cellulitis.  Should  symptoms  point  to  these  conditions,  the  hypo- 
gastric wound  should  be  opened  and  the  space  of  Retzius  thoroughly 
drained. 

Cystic  Tumors  of  the  Bladder. — The  most  systematic  and 
detailed  study  of  these  rare  growths  is  found  in  Clado's  treatise  on 
Tumors  of  the  Bladder.  His  teaching  in  regard  to  them  may  be 
outlined  as  follows : 

Cysts  are  of  epithelial  origin,  or  arise  from  foetal  inclusion  (der- 
moid cysts). 

Epithelial  cysts  are  equally  common  in  men  and  in  women,  are 
observed  during  any  period  of  life  except  in  early  infancy,  and  are 
most  frequent  between  the  thirtieth  and  fiftieth  years.  They  are 
usually  placed  about  the  base  of  the  bladder  in  the  region  of  the  ves- 
ical neck,  probably  because  the  vesical  glands  are  particularly  abun- 
dant in"  these  regions.     They  may  occupy  the  entire  vesical  cavity, 


TUMORS   OF   THE   BLADDEE.  501 

and  sometimes  are  associated  with  cysts  of  the  kidney  pelvis.  CHni- 
cally,  they  are  distinguished  according  to  size,  as  small  or  large. 

Small  cysts  appear  as  minute  or  medium-sized  vesicles  filled  with 
clear  fluid.  This  may  become  turbid  or  even  blood-stained.  They 
may  be  due  either  to  alteration  of  the  normal  vesical  glands  pro- 
ducing cysts  of  retention,  or  to  local  epithelial  proliferation,  followed 
by  central  softening. 

Large  epithelial  cysts  show  a  tendency  to  become  enucleated  from 
the  vesical  wall  and  form  pedunculated  growths.  Vincent  records  a 
case  in  a  child  between  three  and  three  and  a  half  years  old  in  whom 
the  pedicle  was  so  long  that  the  cyst  passed  through  the  urethra  and 
presented  in  the  vulva. 

Dermoid  cysts  may  invade  the  bladder  primarily  or  may  be  para- 
vesical, communicating  with  the  bladder  by  an  orifice.  Over  forty 
cases  have  been  reported.  These  cysts  are  nearly  always  observed 
in  women,  and  symptoms  develop  between  adolescence  and  old  age. 
The  tumor  is  usually  placed  at  the  base  of  the  bladder.  Sometimes 
it  appears  in  the  form  of  a  polyp  ;  that  is,  it  is  pedunculated.  In  this 
tumor  hair  and  fragments  of  bone  may  be  seen.  These  cysts  always 
contain  hair,  and  the  passage  of  this  in  the  urine  constitutes  a  major 
symptom.     Fragments  of  bone  and  teeth  are  also  at  times  passed. 

Microscopically,  these  cysts  show  the  structure  of  skin  which  con- 
tains sebaceous  glands  and  hair-follicles  in  a  state  of  physiological 
activity.  Even  small  tumors  may  discharge  comparatively  large  quan- 
tities of  hair  for  a  long  time. 

Thirty-two  cases  of  paravesical  dermoid  cysts  have  been  collected 
by  Clado ;  seven  originated  in  the  ovary,  seven  formed  paravesical 
tumors ;  in  eighteen  the  only  symptom  recorded  was  micturition  of 
hair. 

The  dermoid  cyst  usually  remains  latent  until  about  the  twenty- 
first  year,  symptoms  of  the  tumor  becoming  manifest  between  this  and 
the  fortieth  year.  The  tumor  is  usually  placed  in  the  recto-vesical 
septum,  beneath  the  peritoneum.  In  two  cases  it  was  placed  on  the 
apex  of  the  bladder,  between  the  peritoneum  and  the  vesical  wall. 
Sometimes  these  cysts  reach  huge  dimensions,  extending  above  the 
umbihcus,  and  weighing  over  fourteen  pounds.  Hair,  fat  (sometimes 
resembling  soap),  teeth,  or  fragments  of  bone  are  constantly  discharged 
into  the  bladder.  In  one  case,  owing  to  pressure,  retention  developed. 
Calculi  frequently  form,  having  for  their  nuclei  masses  of  hair.  These 
cysts  are  usually  complicated  by  cystitis  of  varying  degrees  of  intensity. 

Varicose  Veins  of  the  Bladder. — ^Aside  from  the  enormous  dis- 
tention of  the  venous  plexus  around  the  bladder,  which  accompanies 


502  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

prolonged  vesical  tenesmus  and  enlarged  prostate,  there  have  been 
observed  a  few  cases  of  true  varicose  veins  of  this  viscus.  The  only- 
symptom  is  profuse  spontaneous  bleeding.  The  diagnosis  must  be 
made  by  cystoscopic  examination.  When  this  is  positive,  and  the 
hemorrhage  repeated  or  threatening,  the  veins  should  be  ligated 
through  suprapubic  cystotomy. 

Paravesical  Tumors. — These  may  be  sohd  or  cystic. 

Myoma  is  the  only  solid  tumor.  Belfield  has  observed  one  case, 
the  growth  springing  from  the  muscular  tunic  and  projecting  as  a 
nodule.  Verhoogen  found  a  myoma  the  size  of  a  child's  head  attached 
to  the  posterior  surface  of  the  bladder  by  a  pedicle  about  as  thick  as 
three  fingers. 

Residual  cysts  are  due  to  proliferation  of  the  remains  of  foetal 
structures.  Englisch  has  described  cysts  of  the  Wolffian  and  Miiller's 
bodies,  of  the  prostatic  utricle,  and  of  the  seminal  vesicles,  also  of  the 
urachus. 

Inclusion  cysts — i.e.,  dermoids — have  been  already  described. 

There  is  but  one  example  of  simple  cyst,  contributed  by  Segond. 
The  tumor  was  found  in  the  muscular  wall  of  the  bladder.  It  was 
tightly  adherent,  Clado  suggests  that  it  may  have  originated  from  an 
intravesical  glandular  cyst. 

Cysts  developing  in  the  prostatic  utricle  and  seminal  vesicles  are 
comparatively  rare.  Utricular  cysts  are  median,  provided  with  a  ped- 
icle attached  to  the  base  of  the  prostate,  and  develop  behind  the  blad- 
der. Those  which  arise  from  dilatation  of  diverticula  of  the  seminal 
vesicle  are  always  lateral.  The  median  cysts  are  due  to  persistence 
of  debris  in  the  duct  of  Miiller. 

Urachus  Cyst. — Very  exceptionally  the  urachus  may  remain  patent 
throughout  its  course  or  at  one  end,  giving  rise  to  a  cyst  or  fistula. 
The  cyst  will  form  an  irregular  fluctuating  hypogastric  tumor  simulat- 
ing sacculated  bladder. 

Hydatid  cysts  develop  in  the  pericystic  tissue.  If  the  cyst  de- 
velops in  either  the  anterior  or  the  posterior  wall  of  the  space  of 
Retzius,  its  direction  of  growth  will  be  limited  by  the  fascia  surround- 
ing this  space.  It  will  then  grow  upward  towards  the  umbilicus,  but 
will  not  reach  higher  than  this  point.  It  may  develop  in  the  cellular 
tissue  separating  the  bladder  from  the  rectum,  or  it  may  occupy  the 
true  pelvis,  in  this  case  growing  upward  towards  the  umbilicus. 

These  cysts  may  be  single  or  multiple,  and  are  prone  to  contract 
adhesions  to  the  bladder  and  pelvic  fascia.  The  primitive  develop- 
ment of  the  tumors  is  in  the  subperitoneal  cellular  tissue :  hence  the 
treatment  of  these  cysts  does  not  necessitate  cystotomy. 


TUMOKS   OF   THE    BLADDER.  503 

A  fluctuating  tumor  projecting  into  the  hypogastrium  should  be 
extirpated  if  possDDle  ;  if  this  is  impracticable,  the  lining  membrane 
should  be  removed  and  the  cavity  drained.  A  cyst  tilling  the  vesico- 
rectal cul-de-sac  should  be  reached  by  the  crescentic  perineal  incision 
described  as  appropriate  for  the  removal  of  the  seminal  vesicles.  It 
can  then  be  enucleated,  extirpated,  or  drained. 

Intravesical  ureteral  cyst  has  been  occasionally  seen  as  a  result 
of  constriction  at  the  entrance  of  this  canal  into  the  bladder,  where 
the  stricture  occurs  at  the  termination  of  the  ureter  on  the  vesical 
mucous  membrane.  In  cases  of  such  exceedingly  rare  conditions 
there  are  generally  hydronephrosis  and  congenital  abnormal  location 
of  the  ureteral  termination. 


CHAPTER   XIII. 

DISEASES    AND    INJURIES    OF    THE    URETERS. 

Anatomy. — The  ureters  are  slightly  flattened,  tough,  white,  fibro- 
muscular  canals,  which  conduct  the  urine  from  the  kidneys  to  the 
bladder,  with  the  investments  of  which  their  three  coats  are  con- 
tinuous. On  an  average  they  are  from  ten  to  twelve  and  one-half 
inches  in  length.  Exceptionally  they  may  be  longer,  though  a  greater 
length  than  fifteen  inches  has  not  been  recorded.  They  are  about 
one-eighth  to  one-sixth  of  an  inch  (three  to  four  millimetres)  in  diam- 
eter, but  are  not  of  uniform  calibre  throughout,  being  slightly  nar- 
rowed— (1)  at  a  point  one  to  one  and  a  half  inches  below  the  kidney 
pelvis ;  (2)  at  the  point  of  entrance  into  the  bladder ;  (3)  at  the  point 
of  crossing  of  the  iliac  artery.  When  strictured  the  ureters  may  be- 
come enormously  dilated,  reaching  the  size  of  the  small  intestine. 

The  course  of  the  ureters  is  in  general  downward  and  inward. 
They  are  separated  by  an  interval  of  about  three  inches  at  their 
upper  portion  and  less  than  two  inches  where  they  enter  the  bladder. 
Their  course  in  their  abdominal  portion  is  indicated  on  the  surface  by 
a  vertical  line  passing  upward  from  the  junction  of  the  inner  and 
middle  thirds  of  Poupart's  ligament.  The  upper  extremity  of  the 
ureter  corresponds  to  a  point  where  this  line  crosses  the  twelfth  rib. 
The  lower  extremity  of  the  abdominal  portion  of  the  ureter,  corre- 
sponding to  the  crossing  of  the  bifurcation  of  the  common  iliac  artery, 
is  placed  slightly  below  the  point  where  this  vertical  line  intersects 
a  line  joining  the  two  anterior  superior  iliac  spines.     (Tourneur.) 

At  its  point  of  origin  from  the  kidney  pelvis  the  ureter  lies  on  a 
plane  behind  that  of  the  renal  artery.  It  passes  downward  and  in- 
ward, crossing  the  psoas  muscle  obhquely  to  the  bifurcation  of  the 
common  iliac  artery.  In  its  course  it  is  slightly  convex  forward  and 
inward.  About  the  middle  of  its  course,  or  a  little  below  this  point, 
the  abdominal  portion  of  the  ureter  is  crossed  by  the  spermatic 
artery  in  the  male  and  by  the  ovarian  vessels  in  the  female.  In 
front  he  the  caecum  and  the  ascending  colon  on  the  right  side,  the 
sigmoid  flexure  on  the  left  side. 

The  pelvic  portion  of  the  ureter  describes  a  curve  with  its  con- 
cavity forward,  inward,  and  upward.     It  passes  beneath  the  perito- 

504 


DISEASES   AND   INJUEIES   OF   THE    URETEKS. 


505 


neum,  along  the  walls  of  the  pelvis,  and,  entering  the  posterior  false 
ligament  of  the  bladder,  crossed  by  the  vas  deferens  in  the  mab,  ob- 
liquely pierces  the  vesical  coats  just  beneath  the  posterior  extremity 
of  the  seminal  vesicle. 

In  the  female  the  pelvic  portions  of  the  ureters  pass  first  down- 
Avard,  then  forward  and  inward,  in  the  loose  cellular  tissue  of  the 
pelvis.  In  the  base  of  the  broad  ligament  they  lie  beneath  the  uterine 
arteries,  which  are  closely  connected  to  them  for  a  short  distance  as 
they  pass  upward  to  the  uterus  ;  the  ureters  are  continued  forward 
over  the  anterior  vaginal  vault  into  the  bladder. 

Fig.  164. 


Showing  the  musculature  of  the  trigone.    (Young.) 


The  vesical  portion  of  the  ureter,  about  half  an  inch  in  length, 
runs  obliquely  inward  and  forward  through  the  muscular  layer  of  the 
bladder-walls,  opening  into  the  cavity  of  this  viscus  by  a  slit-hke 
orifice.     (Fig.  164.) 

The  muscles  of  the  ureter  are  continuous  with  those  of  the  bladder. 
Testut  describes  a  valve-like  arrangement  due  to  absence  of  muscular 
tissue  in  the  upper  wall  of  the  terminal  extremity  of  the  ureter. 
This  portion  of  the  wall  is  made  up  entirely  of  a  fold  of  mucous 
membrane ;  intravesical  tension  at  once  presses  this  valve-like  fold 
against  the  low  ureteral  wall,  and  thus  effectually  blocks  the  tube. 


506  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

The  relation  of  the  ureter  to  the  peritoneum  is  extremely  impor- 
tant from  a  surgical  stand-point.  Cabot  has  shown  that  if  the  surgeon 
in  stripping  up  the  peritoneum  has  reached  the  place  where  it  refuses 
to  separate  readily  from  the  parietes,  he  will  find  the  ureter  upon  the 
stripped-up  peritoneum  on  the  left  side  from  half  an  inch  to  an  inch 
outside  this  point ;  on  the  right  side  at  a  somewhat  greater  distance, 
owing  to  the  ureter  being  displaced  laterally  by  the  interposition  of  the 
vena  cava  between  it  and  the  spine. 

The  pelvic  ureter  of  the  left  side  lies  anterior  to  and  to  the  outer  side 
of  the  internal  iliac  artery  close  to  the  rectum ;  that  of  the  right  side 
passes  downward  parallel  to  the  internal  iliac  artery  and  directly  in 
front.  As  these  canals  descend  they  are  covered  by  peritoneum  to  the 
point  where  this  membrane  is  reflected  upward  over  the  posterior  wall 
of  the  bladder,  leaving  nearly  an  inch,  which  can  be  incised  through 
the  vesical  walls  without  opening  the  peritoneal  cavity. 

The  mucous  membrane  of  the  ureter  is  continuous  with  that  of 
the  kidney  pelvis  and  of  the  bladder,  and  is  of  the  type  common  to 
the  urinary  tract.  Glands  are  either  rudimental  or  absent.  The 
mucous  surface  is  made  up  of  layers  of  stratified  squamous  or 
transitional  epithelium.  Beneath  these  are  layers  of  cylindrical  or 
conical  cells.     The  deepest  layer  is  made  up  of  small  rounded  cells. 

The  blood-supply  is  derived  from  branches  of  the  renal,  sper- 
matic or  ovarian,  and  hypogastric  arteries.  These  vessels  supply  a 
plexus  which  abundantly  provides  for  repair  in  case  of  injury.  The 
nerves  are  derived  from  the  renal,  spermatic,  and  hypogastric  plexuses. 

From  its  strong  muscular  coat,  it  is  evident  that  the  ureter  is  not 
merely  a  channel,  but  takes  an  active  part  in  conveying  the  secretion  of 
the  kidney  into  the  bladder.  It  is  well  established  that  the  unstriped 
muscular  fibres  of  the  ureter  are  in  a  state  of  intermittent  peristalsis. 
This  action  goes  on  alternately  within  the  two  ureters,  though  occa- 
sionally it  may  be  synchronous.  The  contractions  are  repeated  at 
irregular  intervals,  and  the  quantity  of  urine  discharged  at  each  con- 
traction varies  greatly,  probably  averaging  from  fifteen  to  thirty  drops. 

Anomalies. — The  ureter  may  be  absent.  In  this  case  the  kidney 
also  will  be  absent.  Bruner  has  collected  forty-eight  cases  of  this 
anomaly.  It  may  be  obliterated  through  a  part  or  the  whole  of  its 
course. 

The  ureter  may  be  multiple ;  the  supernumerary  ureters  often 
coalesce  in  some  part  of  their  course,  but  they  may  remain  sepa- 
rate throughout.  Double  ureter  is  usually  associated  with  a  kidney 
which  has  two  pelves.  Nine  cases  of  bilateral  duplication  are  reported. 
(Levison") 


DISEASES    AND   INJUEIES   OF    THE    URETERS.  507 

The  ureter  may  pursue  an  errant  course.  This  anomaly  appears 
to  be  confined  to  females.  Cases  are  recorded  in  which  the  ureters 
opened  into  the  external  urinary  meatus,  the  vagina,  and  a  pouch 
near  the  bladder. 

Rayer  reports  a  case  in  which  there  was  congenital  absence  of 
the  ureters,  bladder,  and  kidneys  ;  a  flow  of  fluid  having  a  urinous 
odor  came  from  the  umbilicus. 

Valve-formation  is  an  anomaly  of  serious  import,  since  it  leads  to 
hydronephrosis.  In  place  of  leaving  the  renal  pelvis  by  a  funnel- 
shaped  orifice  at  its  lowest  portion,  the  ureter  may  emerge  from  the 
side  of  this  sac,  often  at  an  acute  angle  ;  or  it  may  run  for  some 
distance  in  the  wall  of  the  kidney  pelvis. 

The  operation  for  the  rehef  of  obstruction  due  to  valve-forma- 
tion was  proposed  and  successfully  performed  by  Fenger.  The 
kidney  pelvis  is  exposed  by  the  lumbar  extraperitoneal  incision.  The 
hydronephrotic  sac  is  opened  by  a  longitudinal  incision,  and  search  is 
made  for  the  ureteral  orifice.  Should  this  not  be  found,  the  ureter 
should  be  incised  below  the  sac,  and  a  probe  should  be  passed 
through  this  opening  into  the  pelvis  of  the  kidney.  The  valve,  or  the 
inner  ureteral  wall,  should  the  obstruction  be  caused  by  the  ureter 
running  upward  in  the  pelvic  wall,  is  divided  from  above  downward 
to  the  most  dependent  part  of  the  sac.  The  resulting  longitudinal 
wound  may  be  closed  by  drawing  its  corners  together,  thus  convert- 
ing it  into  a  transverse  wound  (Fenger),  by  applying  numerous  fine 
catgut  sutures  along  the  whole  course  of  the  incision  (Mynter),  or  by 
turning  the  flaps  out  and  sewing  them  to  the  inner  wall  of  the  sac. 
(Kuster  and  Trendelenburg.) 

Wounds  and  Rupture  of  the  Ureters. — From  the  position  of 
the  ureters  it  is  obvious  that  wounds  of  these  canals,  except  those 
inflicted  during  the  course  of  surgical  operations,  are  usually  attended 
by  injuries  of  other  organs  so  extensive  and  immediately  threatening 
to  life  that  the  traumatism  inflicted  upon  the  ureters  is  of  minor  im- 
portance. The  ureter  may  be  wounded  by  direct  violence,  as  by  a 
stab  or  a  bullet,  or  may  be  ruptured  by  indirect  violence,  as  by  a  crush 
or  a  blow.  In  the  course  of  abdominal  section  for  the  removal  of 
malignant  growth,  division  of  the  ureter  is  comparatively  common. 

As  a  result  of  rupture  of  the  ureter  there  is  extravasation  of  urine. 
Since  this  is  sterile  it  does  not  necessarily  excite  cellulitis,  and  in  case 
the  ureter  is  not  completely  torn  across  the  opening  may  cicatrize 
and  the  extravasated  urine  may  be  absorbed  or  become  encapsu- 
lated, in  the  latter  case  producing  the  condition  known  as  pseudo- 
hydronephrosis.    If  there  is  concomitant  infection  cellulitis  will  result, 


508  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

which,  unless  promptly  recognized  and  treated  surgically,  is  liable  to 
become  rapidly  diffuse  and  terminate  fatally.  Following  cicatrization 
of  wounds  strictures  are  formed  causing  hydronephrosis,  and,  fmally,. 
total  destruction  of  the  kidney. 

When  after  a  blow  in  the  lumbar  region  there  is  passage  of  bloody 
urine  Avith  the  formation  of  a  post-peritoneal  tumor  which  fluctuates 
and  rapidly  and  progressively  increases,  rupture  of  the  ureter  may  be 
suspected,  and  the  diagnosis  may  be  confirmed  by  aspiration.  When, 
some  weeks  or  months  after  injury  to  the  ureteral  region,  symptoms 
of  hydronephrosis  develop,  these  symptoms  will  suggest  partial  lacera 
tion  of  the  ureter  followed  by  cicatricial  contraction. 

Wounds  of  the  ureter  inflicted  during  the  course  of  intra-abdom- 
inal operations  are  usually  recognized,  because  the  white,  fibrous,, 
thick-walled  canal  is  easily  identified,  and  because  there  will  probably 
be  escape  of  urine  into  the  wound. 

Accidental  ligation  of  a  single  ureter  usually  causes  typical  renal 
colic,  followed,  if  the  condition  be  unrelieved,  by  atrophy  of  the- 
corresponding  kidney. 

Treatment. — When  symptoms  point  to  rupture  of  the  ureter 
without  external  wound,  there  should  be  no  hesitation  in  cutting 
down  directly  to  the  seat  of  rupture,  going  in  behind  the  peritoneum, 
if  this  is  practicable,  draining  the  tissues  of  the  extravasated  urine,, 
and  restoring  the  continuity  of  the  canal.  When  there  is  an  external 
wound  through  which  the  urine  escapes,  this  wound  should  be  followed 
down  to  the  ureter. 

If  the  wound  communicates  with  the  peritoneal  cavity,  the  in- 
cision of  choice  would  be  an  abdominal  one  ;  after  closure  of  the 
ureteral  opening  a  fold  of  peritoneum  should  be  brought  over  it  on 
both  sides  and  carefully  sutured. 

Extraperitoneal  wounds,  if  longitudinal,  do  not  require  suture,, 
since  they  heal  without  subsequently  encroaching  upon  the  lumen 
of  the  canal.  If  transverse  and  involving  half  of  the  lumen  of  the 
ureter,  even  though  they  be  sutured  and  unite  by  iirst  intention,, 
there  is  likely  to  be  cicatricial  contraction  which  will  ultimately 
cause  stricture.  Schopf's  case,  in  which  a  transverse  suture  was 
performed,  the  patient  perishing  about  two  months  later  of  tubercu- 
losis, presented  an  extensive  cicatrix  at  the  seat  of  union.  Tuffier's 
experiments  on  dogs  clearly  demonstrate  the  tendency  towards 
stricture  formation. 

Transverse  wounds  may  be  treated  by  changing  the  transverse  cut 
into  one  which  is  longitudinal.  Complete  division  of  the  ureter  may 
be  treated  by  end-in-side  (Van  Hook),  end-to-end,  or  end-in-end  suture. 


DISEASES   AND    INJUKIES    OF    THE   UEETERS. 


)09 


(Figs.  165-168.)  From  the  middle  of  the  transverse  cut  incisions  are 
carried  upward  and  downward  through  the  ureteral  walls  for  a  suffi- 
cient diBtance ;  the  four  corners  formed  by  these  cross-cuts  are 
trimmed  off,  and  the  resulting  wound  is  united  transversely  by  folding 
the  ureter  on  itself.     (Fenger.) 


Fig.  165. 


Fig.  166 


End-to-end  anastomosis. 


End-in-side  anastomosis;  first  stage. 


Van  Hook's  method  of  ureteral  nn plantation  is  thus  performed : 
The  lower  end  of  the  ureter  is  ligated  from  one-eighth  to  one-fourth 
of  an  inch  from  its  free  end.  With  a  sharp-pointed  scissors  a  longi- 
tudinal cut  is  made  in  the  lower  end  of  the  ureter,  twice  as  long  as  its 
diameter,  one-fourth  of  an  inch  below  the  ligature.  The  upper  end 
■of  the  ureter  is  split  by  passing  a  point  of  the  scissors  one-fourth  of  an 
inch  within  its  lumen  and  cutting  through  the  wall.  Two  very  small 
needles,  placed  on  each  end  of  a  sterilized  catgut  suture,  are  then 
passed  through  the  wall  of  the  upper  ureteral  end  one-eighth  of  an 
inch  from  its  extremity ;  the  needle-punctures  are  made  from  one- 
sixteenth  to  one-eighth  of  an  inch  apart,  and  are  equally  distant  from 
the  end  of  the  ureter.  (Fig.  16Q.)  The  needles  are  then  carried 
through  the  slit  in  the  side  of  the  lower  end  of  the  ureter  and  along 
the  lumen  of  the  canal  for  half  an  inch  ;  at  this  point  they  are  pushed 
through  the  ureteral  wall  side  by  side.  (Fig.  166.)  Traction  upon 
the  catgut  suture  will  pull  the  upper  ureteral  extremity  into  the  slit 
made  in  the  lower  extremity.  When  this  has  been  done  the  ends  of 
the  loop  are  securely  tied.     (Fig.  166.)     If  this  operation  has  been 


.510 


GENITO-URINARY   DISEASES    AND   SYPHILIS. 


done  through  the  peritoneal  cavity  it  should  be  completed  by  covering 
the  seat  of  suture  by  a  double  layer  of  peritoneum.  The  implanta- 
tion may  be  strengthened  by  one  or  two  sutures  securing  the  wall 
of  the  proximal  ureteral  end  to  the  margins  of  the  longitudinal  incision 
made  in  the  distal  end. 

In  case  of  dilatation  of  the  upper  end  to  be  united,  Emmet  suggests 
puckering  this  end  by  three  sutures  to  draw  the  upper  end  in  place. 
(Fig.  167.) 

The  transverse  end-to-end  has  been  done  twelve  times  with  two 
deaths.     The  end-in-end  method  has  been  employed  ten  times  with 


Fig.  167. 


Fig.  168. 


End-in-side  anastomosis;  second  stage. 


End-m-side  anastomosis,  witn 
reinforcing  sutures. 


one  death.  The  general  principle  of  this  method  is  the  employment 
of  one  or  more  traction  sutures  to  admit  and  maintain  the  insertion  of 
the  upper  into  the  lower  segment.  The  end-in-side  method  necessi- 
tates ligation  of  the  free  end  of  the  lower  segment  and  implantation  of 
the  upper  segment  into  a  slit  made  in  the  side  of  the  lower  end  just 
below  the  ligature,  where  it  is  held  by  a  traction  suture.  The  oblique 
end-to-end  method  is  like  the  first,  except  that  the  ends  are  divided  ob- 
liquely instead  of  transversely,  to  diminish  the  danger  of  stenosis.  It 
requires  a  somewhat  longer  suture.  This  operation  is  recorded  twice 
with  no  mortality. 

The  reported  cases  all  give  favorable  results,  and  even  hasty  and 


DISEASES    AND    INJURIES    OF   THE    UEETERS.  51 1 

faulty  methods  have  been  successful.  The  canal  seems  to  be  adapted 
to  purposes  of  anastomosis,  and  this  should  always  be  attempted 
before  sacrificing  the  kidney  or  implanting  the  ureter  into  the  skin  or 
vagina. 

When  the  ureter  is  torn  across,  and  so  much  of  it  is  destroyed 
that  lateral  implantation  is  not  possible,  it  should  be  implanted  into 
the  bladder,  if  this  is  practicable,  by  either  the  extraperitoneal  or 
the  intraperitoneal  route  ;  the  latter  is  usually  the  only  feasible  method 
of  performing  the  operation. 

Intravesical  Implantation. — Penrose's  successful  method  is  best 
performed  by  passing  a  sound  through  the  urethra,  and  by  means  of 
the  tip  causing  the  wall  of  the  emptied  bladder  to  project  at  a  point  as 
near  the  trigone  as  the  conditions  will  allow.  A  short  antero-posterior 
incision  is  made  on  the  point  of  the  sound.  The  divided  end  of  the 
ureter  is  then  split  for  a  short  distance  on  each  side,  or  incised 
obliquely,  and  is  carried  into  the  bladder  for  some  distance,  as  in  the 
end-to-side  ureteral  implantation,  to  allow  one  or  two  sutures  to  secure 
the  ureter  to  the  external  bladder-wall,  and,  finally,  a  loose  fold  of 
peritoneum  or  omentum  is  fastened  around  the  utero-vesical  anasto- 
mosis. This  fold,  designed  to  prevent  leakage  and  add  strength  to  the 
junction,  must  not  be  drawn  tight  enough  to  cause  constriction.  The 
distal  portion  of  the  divided  ureter  should  be  ligated  close  to  the  blad- 
der and  removed,  the  cross-section  above  the  ligature  being  cauterized 
with  pure  carbolic  acid.     Drainage  is  not  required. 

Stoeckel  reports  seventeen  cases  of  implantation  into  the  bladder 
with  good  functional  results  in  all  but  one  ;  in  this,  traction  prevented 
healing. 

Bover  reports  twenty-seven  uretero-ureteral  anastomoses  with  a 
mortality  of  seven  and  five-tenths  per  cent. ;  seventy-nine  implanta- 
tions into  the  bladder,  thirty-seven  of  which  were  for  injury  during 
operation,  with  two  deaths  ;  and  forty-two  of  which  were  for  cure  of 
fistulae,  with  one  operative  death.  Three  have  since  died,  two  of 
kidney  complications  at  a  later  period. 

If  the  ureteral  defect  is  so  far  removed  from  the  bladder  that 
neither  vesical  implantation  nor  ureteral  juncture  is  possible,  the  two 
ends  may  be  brought  to  the  surface,  as  proposed  by  Rydygier,  and  an 
effort  made  to  connect  them  by  forming  a  channel  of  skin.  Or  the 
ureter  may  be  implanted  upon  the  skin  surface  or  into  the  colon. 
Implantation  into  the  colon  is  difficult,  and  in  the  light  of  present 
evidence  may  be  expected  practically  always  to  be  followed  by  kidney 
infection.  Colonic  implantation  is  attended  by  a  heavy  mortality  (sixty- 
one  per  cent.,  Keyes),  ascending  infection  being  common  even  when 


512  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

the  ureters  are  made  to  traverse  the  walls  of  the  bowel  obliquely  and 
their  orifices  are  protected  by  a  tongue-shaped  flap  of  mucous  mem- 
brane. Hence  this  procedure  should  be  reserved  for  cases  of  ex- 
strophy, and  should  be  performed  in  the  manner  suggested  by  Maydl 
(see  page  396),  which  gives  a  mortality  of  a  little  over  twenty  per 
cent. 

Ureteritis. — Inflammation  of  the  ureters  is  due  to  infection.  This 
extends  from  the  bladder,  as  in  gonorrhoea,  from  the  kidney,  as  in 
pyonephrosis  of  haematogeno us  origin  or  tuberculosis,  or  from  peri- 
ureteric tissues,  as  in  peritonitis  or  cellulitis.  Congestion  strongly 
predisposes  to  infection,  and  is  caused  by  traumatism,  pressure  of 
tumors,  distention  of  the  ureters,  lodgement  or  passage  of  calculus  or 
clot,  or  the  passage  ot  irritating  urine. 

The  lesions  produced  by  ureteritis  are  similar  to  those  observed 
in  cystitis.  In  the  absence  of  distinct  glands  in  this  part  of  the  uri- 
nary tract,  complications  akin  to  folliculitis  and  periurethral  abscess 
observed  in  urethritis  are  not  likely  to  occur. 

As  a  result  of  hyperaemia  and  inflammatory  swelHng  it  is  apparent 
that  the  lumen  of  the  ureters  may  be  seriously  encroached  upon.  If 
the  inflammation  extends  beyond  the  mucous  membrane,  involving 
the  muscular  coat,  there  may  be  resulting  atrophy,  with  loss  of  peri- 
slaltic  power.  From  long-standing  inflammation  and  the  deposition 
of  inflammatory  material  strictures  may  form. 

Jaksch  reports  a  case  of  membranous  ureteritis  in  which  trans- 
lucent casts  of  the  ureter  were  discharged  from  the  urine. 

Symptoms  of  ureteritis  are  not  definite.  It  is  nearly  always  asso- 
ciated with  cystitis  or  pyelitis,  the  symptoms  of  which  completely 
mask  the  inflammation  of  the  ureter.  Tenderness  on  palpation  is 
perhaps  the  only  symptom  which  would  even  suggest  inflammation. 
In  the  urine  there  may  be  found  masses  of  squamous  epithelium 
without  pus.     (Garceau.) 

Kelly  states  that  a  normal  ureter  can  be  traced  and  immediately 
examined  in  the  upper  part  of  the  pelvic  course  by  introducing  a 
ureteral  catheter  and  carrying  it  up  to  or  over  the  brim  of  the  pelvis. 
When  an  inflexible  catheter  is  thus  carried  over  the  brim  the  ureter  is 
displaced  upward  and  straightened  out.  It  can  now  be  palpated 
almost  as  plainly  through  the  rectum  on  the  catheter,  and  any  altera- 
tions in  its  calibre  noted  almost  as  minutely  as  when  laid  bare  by 
dissection.     The  pelvic  brim  can  also  be  felt  per  rectum. 

The  palpation  of  the  ureter  through  the  abdominal  wall  for  the 
purpose  of  detecting  tenderness  is  sometimes  practicable,  pressure 
being  made  at  the  intersection  of  the  line  joining  the  anterior  superior 


DISEASES   AND    INJURIES    OF    THE    UEETEES.  513 

iliac  spines  with  one  vertical  to  this  running  upward  from  the  junction 
of  the  inner  and  middle  thirds  of  Poupart's  ligament.  Clinical  experi- 
ence has  shown,  however,  that  even  extreme  tenderness  elicited  by 
deep  pressure  over  this  spot  is  not  pathognomonic  of  ureteritis. 

Treatment. — The  treatment  of  ureteritis  is  that  of  the  main  disease 
which  masks  it.  Instillations  and  irrigations  such  as  are  used  in  the 
treatment  of  cystitis  are  serviceable. 

Israel,  having,  without  benefit,  performed  nephrotomy  for  the  relief 
of  symptoms,  exposed  the  whole  ureter.  This  canal,  though  per- 
vious, was  chronically  thickened  and  two  or  three  times  its  normal 
size,  and  in  places  was  almost  cartilaginous.  Nephrectomy  was  per- 
formed, and  a  cure  resulted.  Reynier,  after  removing  a  purulent 
cystic  kidney  by  nephrectomy,  noted  that  a  purulent  discharge  from 
the  ureter  persisted,  associated  with  pyrexia.  He  removed  the  whole 
of  the  ureter,  thus  effecting  a  cure. 

Stricture  of  the  Ureter. — This  may  be  congenital  or  acquired. 
The  acquired  stricture  may  be  inflammatory  or  traumatic.  Congeni- 
tal stricture  has  been  regarded  as  the  commonest  form  of  narrowing. 
Tuffier  reports  twenty-nine  cases.  In  fifteen  the  narrowing  was  in 
the  upper  part  of  the  ureter ;  in  the  remainder  it  was  in  the  lower 
part. 

Inflammatory  stricture  is  apparently  more  common  than  patho- 
logical records  would  lead  us  to  believe,  and  is  usually  multiple. 
Watson  has  reported  two  cases. 

Traumatic  strictures  are  necessarily  rare,  since  there  are  compara- 
tively few  cases  of  ureteral  wound. 

The  symptoms  of  ureteral  stricture  are  those  of  back  pressure. 
Should  the  stricture  produce  complete  obliteration  of  the  ureter,  the 
kidney  will  atrophy.  Partial  occlusion  causes  hydronephrosis  and 
great  dilatation  of  the  ureter  above  the  seat  of  narrowing. 

The  diagnosis  of  ureteral  stricture  is  founded  upon  the  develop- 
ment of  hydronephrosis,  and,  in  women,  upon  palpation  and  direct 
exploration  of  the  ureter  by  means  of  catheters  or  bougies.  Cysto- 
scopic  examination  shows  an  abnormal  condition  of  the  ureteral  orifijce 
and  the  surrounding  mucous  membrane.  The  ureteral  catheter  is 
arrested  at  the  seat  of  narrowing ;  when  after  persistent  pressure  it 
has  passed  through  there  is  a  continuous  flow  of  urine.  Injection  of 
fluid,  since  it  results  in  sudden  increase  of  renal  tension,  causes  pain, 
the  coarctation  preventing  the  fluid  from  passing  into  the  bladder  be- 
tween the  catheter  and  the  ureteral  walls.  As  the  instrument  is  with- 
drawn, its  tip  is  felt  to  slip  from  the  grasp  of  the  stricture. 

Speaking  of  women,  Kelly  states  that  "  A  large  percentage  of  cases 

33 


514  GENITO-UEIXARY   DISEASES   AND   SYPHILIS. 

under  treatment  to-day  for  cystitis  and  for  irritable  bladder  are  in 
reality  tender,  thickened  ureters,  and  intelligent  palpation  will  detect 
the  tube,  now  hard  and  cord-like,  bringing  out  the  characteristic  com- 
plaint of  intense  desire  to  urinate.  An  enlarged  ureter  can  easily  be 
further  palpated  per  rectum  behind  the  broad  ligament  and  followed 
from  there  up  over  the  posterior  pelvic  wall." 

The  prognosis  of  ureteral  stricture  is  grave  because  of  the  usually 
associated  renal  involvement.  The  condition  is  rarely  suspected  till 
pyelitis,  hydronephrosis,  or  pyonephrosis  develop.  Strictures  of  the 
lower  segment  are  more  easily  cured  than  higher  ones  ;  those  due  to 
periureteral  contracture  recur  even  when  fully  dilated. 

Treatment. — A  permeable  stricture  may  be  treated  by  (Ij  intermit- 
tent dilatation,  beginning  with  a  bougie  one  millimetre  in  diameter  and 
increasing  to  five  millimetres  ;  the  treatments  being  practised  twice  a 
week,  and  being  preceded  by  vesical  irrigations  and  followed  by  ure- 
teral irrigations  of  boric  acid  1  to  100  or  protargol  1  to  3000.  (2) 
Continuous  dilatation,  the  bougie  being  left  in  place  for  one  or  two 
days  and  then  changed  to  a  larger  instrument  until  full  dilatation  is 
reached.  When  the  stricture  is  not  pervious  from  the  bladder,  or 
when  it  is  impossible  to  pass  an  instrument  into  the  vesical  end  of  the 
ureter,  the  narrowing  may  be  attacked  from  above.  These  cases  are 
always  complicated  by  hydronephrosis  :  hence  it  is  easy  to  enter  the 
pelvis  of  the  kidney  through  its  posterior  wall.  If  the  ureteral  orifice 
of  the  pelvis  cannot  be  found,  the  ureter  can  be  exposed  slightly 
below  this  point,  opened  by  a  longitudinal  incision,  and  explored  above 
and  below  by  bougies  ranging  in  size  from  No.  4  to  No.  12  French. 
If  the  stricture  is  impermeable,  it  may  be  treated  by  longitudinal  in- 
cision and  transverse  union  of  the  resulting  wound,  or  by  excision  and 
the  restoration  of  the  continuity  of  the  ureter  by  uretero-ureterostomy. 
If  none  of  these  procedures  are  practicable,  the  ureter  may  be  divided 
and  implanted  into  the  bladder  or  on  the  skin  surface,  or  the  kidney 
and  ureter  may  be  excised.  This  last  operation  is  usually  indicated 
:zi  cases  of  unilateral  tuberculous  stricture. 

Kiister,  finding  obliteration  of  the  ureter  three  centimetres  below 
the  pelvis  of  the  kidney,  resected  three  centimetres  of  the  ureter,  in- 
cluding the  strictured  portion,  and  fastened  the  distal  end  to  the  lower 
part  of  the  renal  pelvis.  The  patient  was  cured.  Cramer  has  oper- 
ated successfully  on  two  cases, — one  a  hydronephrosis  and  the  other 
a  pyonephrosis, — opening  into  the  ureter  at  the  most  dependent  por- 
'tion  of  the  distended  part  of  the  pelvis.  The  operation  of  Kiister  is 
applicable  only  to  strictures  near  the  kidney.  It  would  not  be  suitable 
if  the  ureter  was  permeable.    In  the  latter  case  the  operation  of  Fenger, 


DISEASES    AND    INJUEIES    OF    THE    URETERS.  515 

making  a  longitudinal  incision  in  the  stricture  and  suturing  in  a  trans- 
verse direction  immediately,  as  in  the  Heinecke-Mikulicz  operation  for 
stenosis  of  the  pylorus,  is  to  be  preferred. 

If  the  stricture  is  found  at  a  point  distant  from  the  place  of  in- 
cision, as  when  the  exploration  has  been  carried  on  through  a  wound 
of  the  kidney,  Albarran  advises  that  there  should  be  a  patient  effort 
to  pass  through  the  stricture  a  "bougie  armee,"  and  then  the  ureth- 
rotome devised  by  him  should  be  slipped  over  this  as  a  guide,  and 
internal  ureterotomy  follow. 

After  having  found  one  stricture,  the  ureter  should  always  be 
sounded,  to  determine  the  presence  or  absence  of  others. 

Calculus  of  the  Ureter. — The  great  majority  of  kidney-stones 
either  remain  lodged  in  or  near  the  pelvis  or,  having  once  entered  the 
ureter,  pass  into  the  bladder.  This  passage  is  often  attended  by  no 
symptoms.  When  the  stone  is  of  such  size  and  shape  that  it  is  arrested 
in  its  passage,  thus  blocking  the  ureter,  a  nephritic  colic  develops. 
Schenck  and  Tenney  note  that  of  one  hundred  and  thirty-four  cases 
of  ureteral  calculi  seventy-four  were  in  females  and  fifty-eight  in  males. 
The  points  of  impaction  correspond  to  the  points  of  narrowing  of  the 
canal.  (See  page  504.)  About  one-quarter  are  lodged  at  the  first 
point  of  narrowing.  A  few  more  than  one-eighth  are  caught,  at  the 
middle  constriction,  and  over  half  of  all  ureteral  calculi  become  im- 
pacted just  above  the  bladder.  They  may  lodge  in  the  intravesical  or 
even  in  the  intramural  portion.  A  single  calculus  is  the  rule,  but  in 
about  one-eighth  of  the  cases  they  are  multiple. 

Symptoms. — The  prodromal  symptoms  of  calculus  in  the  ureter 
may  be  those  of  renal  calculus  or  the  passage  of  gravel  and  small 
concrements  with  the  urine.  Often  the  attack  comes  on  without  pro- 
dromal symptoms.  The  patient  is  seized  suddenly  with  an  agonizing 
pain  radiating  over  the  lumbar  and  hypochondriac  regions,  along  the 
course  of  the  ureter,  to  the  end  of  the  penis,  to  the  testicle  of  the 
affected  side,  and  to  the  inner  surface  of  the  thigh.  The  pain  is 
usually  continuous,  with  exacerbations.  It  may  be  felt  in  the  belly, 
chest,  shoulders,  small  of  the  back,  or  sacrum.  The  suffering  is  so 
severe  that  the  patient  becomes  blanched,  bathed  in  cold  sweat,  and 
sometimes  collapsed.  There  is  often  reflex  vomiting.  The  testicle 
of  the  affected  side  is  usually  drawn  close  up  to  the  external  ring, 
and  the  abdomen  may  become  tender  and  tympanitic ;  if  there  has 
been  no  infection  of  the  kidney  pelvis,  fever  rarely  develops.  There 
is  often  a  constant  distressing  desire  to  urinate,  with  loss  of  power 
to  empty  the  bladder.  There  may  be  anuria  due  to  reflex  disturb- 
ance of  the  healthy  kidney,  perhaps  more  frequently  attributable  to 


516  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

the  fact  that  the  patient  is  possessed  of  but  one  secreting  kidney,  the 
duct  of  which  is  blocked. 

The  pain  and  reflex  disturbances  are  due  to  retention  of  urine  in 
the  kidney  pelvis  and  the  upper  segment  of  the  ureter.  For  a  time  this 
retention  may  be  absolute,  since  the  irritation  and  congestion  incident 
to  the  arrest  of  the  stone  occasion  swelling  and  spasm  which  are  suf- 
ficient, together  with  the  foreign  body,  to  close  entirely  the  ureteral 
lumen.  These  symptoms  may  last  a  few  minutes,  a  few  hours,  or 
one  or  two  days,  and  their  subsidence  may  be  as  sudden  as  their 
onset.  This  sudden  complete  subsidence  indicates  either  retrogression 
of  the  stone  into  the  kidney  pelvis  or  its  extrusion  into  the  bladder- 
cavity.  The  symptoms  may  subside  gradually,  recurring  at  intervals, 
and  may  be  followed  by  the  gradual  development  of  hydronephrosis. 
This  indicates  that  the  stone  has  been  lodged  in  the  ureter,  and  that 
the  first  absolute  obstruction  has  yielded,  partly  to  dilatation  of  the 
foreign  body,  partly  to  relaxation  of  the  spasm,  and  has  allowed  a 
portion  of  the  urine  to  pass  through.  Under  these  circumstances 
kidney  colic  is  liable  to  recur,  but  with  less  severity. 

During  an  attack  of  colic  the  urine  may  be  absolutely  normal. 
This  points  to  the  existence  of  one  healthy  kidney.  If  blood  is  found, 
it  may  be  taken  as  an  evidence  that  the  obstruction  is  not  complete, 
provided  there  is  no  reason  to  believe  that  the  hemorrhage  comes 
from  the  kidney  or  the  ureter  of  the  unaffected  side.  Immediately 
on  the  subsidence  of  the  attack  a  small  quantity  of  blood  is  constantly 
found  in  the  urine. 

Diagnosis.— The  diagnosis  of  impacted  ureteral  stone  is  based  on 
a  history  of  the  symptoms  of  kidney  calculus  (see  page  554)  and  of 
one  or  more  attacks  of  colic,  followed  by  the  development  of  hydro- 
nephrosis or  pyonephrosis.  When  typical  symptoms  develop,  the 
X-ray  will  often  demonstrate  both  the  seat  and  the  number  of  ureteral 
calculi.  When  the  shadows  are  not  placed  along  the  normal  course 
of  the  ureters,  the  presence  of  phleboliths  or  calcareous  glands  should 
be  suspected. 

Pain  may  be  referred  to  the  healthy  kidney.  Neuman  has  reported 
three  cases  of  this  crossed  renal  pain,  in  two  of  which  calculi  and  in 
one  pyonephrosis  were  found  on  the  side  opposite  that  which  gave 
the  subjective  symptoms. 

Palpation  either  through  the  rectum  or  through  the  abdominal 
walls,  and  ureteral  catheterization  when  possible,  may  enable  the 
surgeon  to  form  a  positive  opinion  as  to  the  presence  of  ureteral 
calculus  ;  but  it  must  be  confessed  that  often  all  diagnostic  means  fail. 
Thus,  a  clear  history  may  be  wanting,  the  patient  perhaps  having 


Fig.  169. 


Multiple  calculi  in  the  ureter.    (Skiagraph  made  by  Dr.  H.  K.  Pancoast.) 


DISEASES   AND    INJURIES   OF   THE    URETEES.  517 

severe  abdominal  pain,  which  is  attributed  possibly  to  gall-stones  or 
to  some  other  intra-abdominal  trouble.  If  the  stone  completely  blocks 
the  ureter,  in  place  of  hydronephrosis  the  kidney  may  atrophy  exactly 
as  it  would  do  if  a  ligature  were  applied  about  the  ureter.  In  fat  sub- 
jects it  is  extremely  difficult  to  develop  a  satisfactory  skiagraph. 

Diagnosis  founded  on  kidney  colic  is  usually  fairly  reliable,  since 
this  pain  is  highly  characteristic.  Yet  it  must  be  remembered  that 
stone  in  the  ureter  has  been  diagnosed  when  the  real  condition  was 
passage  of  a  gall-stone,  appendicitis,  neuritis  of  the  lumbar  nerves, 
spinal  caries,  or  acute  intestinal  obstruction. 

A  careful  examination  of  the  urine  will  enable  the  surgeon  to  de- 
termine whether  or  not  the  symptoms  are  due  to  blocking  of  the 
ureter.  Moreover,  the  conditions  with  which  ureteral  calculus  may 
be  confounded  have  usually  certain  pathognomonic  features  which 
sooner  or  later  manifest  themselves.  Thus,  gall-stone  is  attended 
with  jaundice,  and  the  pain  is  likely  to  be  referred  to  the  region  of 
the  right  shoulder.  Appendicitis  exhibits  increasing  tenderness  on 
pressure  over  McBurney's  point,  the  abdominal  symptoms  become 
rapidly  and  progressively  worse,  and  blood  and  pus  are  not  found  in 
the  urine.  In  neuritis  of  the  lumbar  nerves  the  tenderness  is  super- 
ficial, and  there  is  no  marked  change  either  in  the  quantity  of  urine 
passed  or  in  its  constituents.  The  persistent  vomiting  of  intestinal 
obstruction,  shortly  becoming  fsecal,  and  the  obstinate  constipation, 
would  suggest  the  nature  of  the  affection. 

The  symptoms  are  due  to  obstruction,  and  not  to  the  irritation 
caused  by  the  rough  corners  of  a  stone,  and  they  will  be  as  distinctly 
marked  if  the  obstruction  is  due  to  a  portion  of  tumor,  a  blood-clot, 
or  a  mass  of  inspissated  tubercular  pus.  The  diagnosis  as  to  the 
cause  of  the  obstruction  is  dependent  on  the  previous  history  of  the 
patient. 

Intermittent  pyuria — that  is,  the  passage  of  normal  urine  during 
attacks  of  cohc,  the  passage  of  pus  in  the  urine  during  intervals — 
points  to  the  existence  of  one  healthy  kidney.  The  blocking  during 
the  acute  attacks  is  complete,  hence  no  pus  escapes  into  the  bladder ; 
during  the  intervals,  owing  to  relaxation  of  spasm  or  lessened  con- 
gestion, part  of  the  urine  escapes  on  the  diseased  side,  carrying  with 
it  pus. 

Palpation  will  fail  certainly  in  a  large  majority  of  cases.  It  may, 
however,  show  a  point  of  tenderness,  which  if  constant  is  a  sign  of 
some  value  in  locating  the  stone.  -  If  the  calculus  is  lodged  near  the 
vesical  orifice  of  the  ureter,  it  may  readily  be  felt  in  women.  In  men 
this  is  more  difficult,  bince  the  examining  finger  per  rectum  can  rarely 


518  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

be  extended  as  far  as  the  posterior  extremity  of  the  seminal  vesicles. 
Ureteral  catheterization  may  sometimes  succeed  in  locating  the  seat  of 
obstruction,  and  may  possibly  indicate  the  presence  of  stone.  As  a 
further  means  of  diagnosis,  and  one  always  justifiable  when  the  in- 
tegrity of  the  kidney-substance  is  threatened  by  the  persistence  of 
symptoms,  exploration  by  lumbar  incision  is  valuable.  This  enables 
the  surgeon  to  explore  directly  the  entire  abdominal  ureter,  and  by 
means  of  bougies  to  determine  whether  or  not  the  pelvic  portion  is 
patulous. 

The  diagnosis  between  kidney  calculus  and  blocking  of  the  ureter 
from  unnatural  mobility  of  the  kidney  is  sometimes  absolutely  im- 
possible. The  symptoms  are  precisely  the  same,  and  in  both  cases 
the  urine  may  show  blood  after  the  attack  is  over.  A  movable  kid- 
ney would  be  suggested  by  the  prompt  relief  which  sometimes  fol- 
lows either  abdominal  manipulation  of  the  organ  or  the  assumption 
of  the  dorsal  decubitus. 

Prognosis. — The  calculus  having  passed  into  the  ureter  may 
recede  into  the  kidney  pelvis,  may  pass  on  to  the  bladder,  or  may  be 
permanently  lodged. 

Calculus  lodged  in  the  ureter,  if  it  entirely  blocks  this  canal, 
causes  rapid  and  complete  destruction  of  the  secreting  substance  of 
the  kidney.  Provided  the  other  kidney  is  healthy,  it  is  usually  able 
to  function  for  both.  When  the  obstruction  is  partial  there  is  back 
pressure,  with  more  or  less  dilatation  of  the  ureter,  kidney  pelvis,  and 
cahces,  and  gradual  degeneration  of  the  kidney-substance.  The  con- 
gestion incident  to  this  condition  strongly  predisposes  to  infection. 
As  the  ureteral  walls  dilate  they  commonly  become  thickened. 

The  calculus  may  ulcerate  entirely  through  the  ureteral  wall, 
forming  an  abscess,  which  may  open  externally  in  the  lumbar  region, 
or  into  the  colon,  or  may  follow  the  course  of  perinephritic  abscesses. 

Treatment. — Since  most  stones  which  enter  the  ureter  from  the 
kidney  pelvis  pass  into  the  bladder,  the  early  treatment  of  either  a 
first  agonizing  attack  of  renal  colic  incident  to  calculous  obstruction  of 
the  ureter,  or  of  recurrent  mild  attacks  should  be  palliative.  The 
patient  should  be  given  a  hot  bath,  and  a  full  dose  of  morphine 
hypodermically.  The  administration  of  medicines  by  the  mouth  is 
of  little  service,  since  there  is  usually  vomiting.  A  hot  rectal  enema 
is  useful  in  relieving  the  tympany,  which  is  sometimes  symptomatic 
of  ureteral  obstruction.  When  the  pain  is  so  agonizing  that  it  seri- 
ously affects  the  pulse,  inhalations  of  ether  should  be  given  until  suf- 
ficient time  has  elapsed  for  the  morphine  to  produce  its  quieting  effect. 
The  urgent  desire  to  micturate,  from  which  patients  suffering  from 


DISEASES   AND    INJURIES    OF    THE    URETEKS.  519 

kidney  colic  complain,  is  a  pure  reflex.  There  is  usually  retention, 
probably  spasmodic  in  nature.  It  is  relieved  by  a  hot  sitz-bath,  the 
patient  being  directed  to  urinate  while  sitting  in  the  bath.  If  it  should 
persist,  the  bladder  forming  a  distinct  tumor  above  the  pubis,  the  cath- 
eter should  be  used,  but  only  by  a  surgeon  thoroughly  skilled  in  the 
details  of  genito-urinary  asepsis,  since  the  conditions  for  ascending 
infection  are  peculiarly  favorable  after  the  passage  of  a  stone. 

When  it  is  evident,  from  the  gradual  development  of  a  hydro- 
nephrosis or  the  persistently  recurring  mild  attacks  of  kidney  colic, 
that  a  calculus  is  lodged,  and  that  the  kidney  is  becoming  seriously 
affected ;  when  during  an  acute  attack  the  secretion  of  the  urine  is 
partly  or  completely  suppressed,  suggesting  that  the  patient  has  not 
a  healthy  kidney  on  which  to  fall  back ;  or  when  fever  and  hectic 
develop,  together  with  pus  in  the  urine,  pointing  to  pyonephrosis, — 
surgical  interference  is  imperative. 

Calculi  lodged  in  the  vesical  orifice  of  the  urethra  and  projecting 
into  the  bladder  have  been  removed  by  the  lithotrite  or  through  a  vesical 
opening.  In  women  calculi  frequently  lodge  in  the  portion  of  the 
ureter  lying  within  the  folds  of  the  broad  ligament,  because  of  nar- 
rowing incident  to  disease  of  this  structure.  An  incision  through  the 
anterior  vaginal  vault  upon  such  a  stone,  if  it  be  palpable,  enables  the 
surgeon  to  remove  it  without  opening  either  the  peritoneum  or  the 
bladder. 

Usually  the  safe  removal  of  a  ureteral  calculus  requires  the  ilio- 
lumbar incision.  This  cut  begins  just  below  the  twelfth  rib  at  the 
outer  border  of  the  sacro-lumbar  muscles,  and  is  carried  downward 
and  forward  to  the  middle  of  Poupart's  ligament,  passing  about  an 
inch  above  and  to  the  inner  side  of  the  anterior  superior  spine. at  the 
ileum.     Through  it  the  kidney  and  the  entire  ureter  are  accessible. 

The  incision  is  deepened  till  the  peritoneum  is  exposed  throughout 
the  entire  length  of  the  wound  ;  this  membrane  is  then  stripped  by  the 
finger  from  the  iliac  and  psoas  muscles  till  the  iliac  vessels  are  exposed. 
It  must  be  remembered  that  the  ureter  strips  up  with  the  peritoneum, 
and  that  this  canal  may  be  extremely  difficult  to  recognize  when  it  is 
dilated  and  has  formed  adhesions  as  a  result  of  periureteritis.  When 
a  stone  is  present  and  readily  accessible,  this  forms  a  landmark  which 
makes  the  operation  a  comparatively  easy  one  ;  but  when  the  calculus 
lies  deep  in  the  pelvis,  the  operator  may  experience  considerable  dif- 
ficulty in  identifying  the  ureter  as  a  preliminary  to  following  it  in  its 
downward  course.  This  identification  may  be  facilitated  by  bearing 
in  mind  the  anatomical  relation  of  the  ureter,  remembering  that  it  is 
found  lying  in  contact  with  the  posterior  surface  of  the  peritoneum 


520  GENITO-cTEUSTAKY   DISEASES   AND   SYPHILIS. 

one-half  inch  to  one  inch  external  to  its  point  of  mesenteric  reflection, 
just  in  front  of  the  bifurcation  of  the  common  iliac  artery. 

Young  has  shown  that  the  ureter  may  be  followed  down  to  its 
point  of  entrance  into  the  bladder.  This  is  accomplished  by  freeing 
it  at  the  brim  of  the  pelvis,  making  gentle  traction  upon  it,  drawing 
aside  with  broad  retractors  the  vesical  wall  near  the  peritoneum,  and 
following  the  ureter  by  a  blunt  dissection  into  the  depths  of  the  pelvis. 
The  calculus,  if  present,  may  be  palpated,  and  may  usually  be  pushed 
up  into  a  portion  of  the  ureter  so  accessible  as  to  allow  of  the  intro- 
duction of  sutures.  It  is  customary  to  apply  Lembert  sutures  before 
the  ureteral  incision  is  made.  This  is  not  desirable,  since  the  cut  sur- 
faces should  be  brought  directly  in  contact  rather  than  inverted.  When 
it  is  impossible  to  push  the  calculus  up,  it  may  be  dislodged  by  means 
of  long,  fine  forceps  passed  through  an  incision  so  placed  in  the  dilated 
portion  of  the  ureter  that  sutures  can  be  subsequently  introduced. 
After  removal  of  the  calculus,  the  ureter  should  be  explored  to 
demonstrate  the  absence  of  either  calculi  or  stricture  interfering  with 
the  free  flow  of  urine  into  the  bladder.  It  is  customary  to  drain  these 
wounds ;  where,  however,  the  urine  is  sterile  and  the  operation  does 
not  require  much  handling  of  tissue,  they  should  be  closed  without 
drainage.  To  insure  against  subsequent  weakness  of  the  abdominal 
walls,  the  large  muscular  wound  should  be  very  accurately  closed  by 
broad  mattress  sutures  of  chromicized  catgut. 

For  the  removal  of  calculi  lodged  in  the  upper  portion  of  the 
ureter,  the  parietal  incision  need  be  prolonged  no  further  than  to  a 
point  an  inch  above  the  anterior  superior  iliac  spine.  If  it  is  possible 
to  push  the  calculus  back  into  the  renal  pelvis,  Albarran  advises  its 
removal  through  a  nephrotomy  wound. 

Calculi  lodged  in  the  pelvic  portion  of  the  ureter  can  be  reached 
through  the  lower  half  of  the  ilio-lumbar  incision  or  through  a  vesical 
cut  carried  from  the  insertion  of  the  rectus  muscle  four  inches  upward 
(Witherspoon).  The  muscle  is  torn  through  in  the  direction  of  the 
fibres  and  the  fascia  is  cut,  exposing  the  peritoneum  which  is  stripped 
up  from  the  abdominal  wall  as  far  as  the  ilio-pectineal  line.  The 
finger  is  then  passed  to  the  vesical  base,  pushing  upward  and  inward 
the  lateral  false  ligament  of  the  bladder,  and  separating  the  peritoneum 
from  the  pelvic  wall  as  far  back  as  the  vas  deferens  ;  by  following  this 
canal  for  two  inches  from  its  point  of  crossing  the  obturator  vessels, 
the  ureter  will  be  reached  passing  behind  it.  Both  these  canals  strip 
up  with  the  peritoneum.,  and  the  ureter  may  be  palpated  as  far  as  the 
brim  of  the  pelvis.  The  operation  is  bloodless  and  leaves  a  strong 
abdominal  wall. 


DISEASES   AND   INJURIES    OF   THE    URETERS.  521 

Before  closing  the  wound,  the  ureter  must  be  catheterized  to  ascer- 
tain if  any  other  calculi  are  present,  or  if  there  is  any  narrowing  of  its 
lumen.  The  exploratory  catheterization  of  the  ureter  is  at  times  dif- 
ficult ;  exceptionally,  an  instrument  cannot  be  passed  from  above 
downward.  In  these  cases  Albarran  advises  catheterization  from 
below  upward  by  the  endoscope,  or,  if  necessary,  by  suprapubic 
cystotomy. 

The  mortality  of  uretero-lithotomy  when  uncomplicated  by  anuria, 
pyelitis,  or  pyelonephrosis  is  less  than  six  per  cent. 

Fistula  of  the  Ureter. — Fistulse  are  secondary  to  wounds,  rup- 
ture, or  ulceration  of  the  ureters.  A  longitudinal  wound  may  heal 
spontaneously  without  the  formation  of  either  fistula  or  stricture ; 
transverse  wounds  involving  half  the  diameter  of  the  ureter,  and  par- 
ticularly when  they  completely  sever  it,  are  followed  by  fistulse. 

These  wounds  are  usually  inflicted  during  the  course  of  gynaeco- 
logical operations.  Spontaneous  fistula— i.e.,  that  due  to  ulceration — 
is  caused  by  tubercular  infiltration,  malignant  growth,  calculus,  or 
foreign  body ;  the  fistula  under  such  conditions  is  secondary  to  par- 
tial or  complete  ureteral  obliteration. 

A  fistula  may  open  on  the  surface  of  the  body  or  into  the  cavity  of 
a  neighboring  viscus.  The  surface  opening  is  commonly  in  the  lum- 
bar region  ;  it  may  be  found  in  the  groin  or  in  some  portion  of  the 
anterior  abdominal  parietes.  Visceral  opening  is  commonly  into  the 
uterus  or  vagina,  but  may  be  into  the  rectum,  and  very  exceptionally 
into  the  stomach.  The  patulous  tract  is  apt  to  be  fairly  direct ;  it  may 
be  long  and  irregular. 

Symptoms. — The  pathognomonic  symptom  of  ureteral  fistula  is  a 
continuous  or  intermittent  discharge  of  urine.  Duplay  and  Rectus 
state  that  if  the  fistula  is  near  the  kidney  the  flow  of  urine  is  continu- 
ous. If  it  is  low  down  towards  the  vesical  extremity  the  flow  is  inter- 
mittent, coming  in  jets.  The  urine  may  remain  perfectly  clear,  showing 
no  admixture  of  pus  or  kidney  albumen.  For  diagnostic  purposes 
methylene  blue  may  be  given  by  the  mouth. 

Diagnosis. — The  diagnosis  between  ureteral  and  vesical  fistulse 
can  be  established  by  injecting  colored  fluids  into  the  bladder.  Renal 
fistulEe  are  fairly  direct,  and  but  a  slight  amount  of  urine  escapes  from 
them  if  the  ureter  is  pervious.  Catheterization  of  the  ureter  and  in- 
jection of  colored  fluid  will  sometimes  be  serviceable  in  establishing 
a  diagnosis. 

Prognosis. — There  is  little  tendency  towards  spontaneous  cure 
of  ureteral  fistula.  Provided  narrowing  of  the  orifice  does  not  take 
place,  the  fistula  may  produce  -no  appreciable  effect  upon  the  general 


522  GEXITO-UEIXAEY   DISEASES   AND   SYPHILIS. 

health.  It  often  happens  that,  because  of  gradual  cicatricial  forma- 
tion and  encroachment  upon  the  ureteral  calibre,  hydronephrosis 
develops.  It  should  be  remembered  that  in  case  the  ureter  is  en- 
tirely divided,  the  lower  extremity  becomes  atrophic  from  disuse, 
thus  making  an  operation  for  the  restoration  of  the  continuity  of  the 
channel  extremely  difficult. 

Treatment. — The  first  requisite  of  successful  treatment  is  that  the 
ureter  shall  be  restored  to  its  normal  calibre.  It  is  possible  that  this 
may  be  accomplished  by  the  use  of  ureteral  bougies  or  continuous 
ureteral  catheterization  practised  through  the  bladder.  Usually  the 
ureter  is  impervious. 

When  the  fistula  opens  into  the  vagina,  colpocleisis  may  be  per- 
formed. This  operation,  first  practised  by  Hahn,  converts  a  part  of 
the  vagina  into  an  artificial  reservoir  for  the  urine.  Kelly  in  one  case 
of  uretero-vaginal  fistula  closed  the  ureter  by  suture.  When  the 
vesical  extremity  of  the  canal  is  obliterated  the  ureter  may  be  im- 
planted into  the  bladder  by  the  intraperitoneal  or  the  extraperitoneal 
route. 

When  the  fistula  involves  the  abdominal  portion  of  the  ureter, 
direct  closure,  splitting  of  the  ureter  and  transverse  suture,  or  ex- 
cision of  the  diseased  area,  followed  by  ureterostomy,  may  be  indi- 
cated. When  it  is  placed  high  in  the  ureter,  it  may  be  resected, 
together  with  a  segment  of  the  ureter,  and  this  canal  may  be  sutured 
to  the  renal  pelvis. 

Cure  may  be  accomplished  by  nephrectomy.  This  operation  has 
been  many  times  successfully  performed.  It  should,  however,  be 
left  as  a  last  resort,  efforts  being  made  either  to  restore  the  con- 
tinuity of  the  ureter  or  to  implant  it  into  the  bladder. 

Tuberculosis  of  the  Ureter, — Tubercular  involvement  of  the 
ureter  is  usually  secondary  to  tubercular  disease  of  the  bladder  or  the 
kidney.  The  infiltration  attacking  a  portion  of  the  ureter  and  par- 
tially or  completely  obliterating  it  may  produce  dilatation  of  the  seg- 
ment above,  and  hydronephrosis  or  pyonephrosis  ;  or  the  entire 
ureter  may  be  infiltrated,  becoming  a  dense,  often  nodular,  imper- 
vious cord. 

The  symptoms  of  tubercular  infiltration  of  the  ureter  are  usually 
completely  masked  by  those  of  vesical  or  renal  disease.  In  women 
palpation  of  the  lower  extremity  of  the  ureter  through  the  vaginal 
vault  might  show  characteristic  induration  and  nodulation.  In  both 
sexes  attempts  at  ureteral  catheterization  would  demonstrate  points 
of  narrowing. 

The  treatment  of  ureteral  tuberculosis  cannot  be  formulated,  since 


DISEASES   AND   INJURIES   OF    THE    URETERS.  523 

this  is  never  encountered  clinically  as  an  isolated  lesion.  If  in  the 
course  of  a  nephrectomy  for  tubercular  kidney  the  ureter  is  found 
involved,  it  should  be  removed  with  the  kidney. 

Tumors  of  the  Ureter. — Tumors  of  the  ureter  have  been  re- 
ported in  a  few  instances,  this  canal  having  been  secondarily  involved 
by  malignant  growth,  extending  from  either  the  kidney  pelvis  or  the 
b'adder,  Albarran  collected  thirty-two  such  cases.  Target  found  a 
large  round-celled  sarcoma,  involving  the  whole  length  of  the  right 
ureter,  and  Chrobak  reports  a  subserous  myoma. 

The  diagnosis  of  these  rare  tumors  is  scarcely  possible.  The 
symptoms  are  those  of  ureteral  obstruction  and  haematuria.  Bloody 
non-purulent  urine  containing  masses  of  squamous  epithelial  cells 
following  ureteral  catheterization  in  a  patient  over  fifty  would  be  sug- 
gestive of  ureteral  neoplasm.  (Albarran.)  The  ureteral  papillse  are 
the  most  frequent  seats  of  ureteral  cancer.  The  disease  here  may  be 
recognized  by  the  cystoscope.  The  treatment  indicated  is  complete 
nephro-ureterectomy.  Of  thirteen  such  operations  there  were  three 
deaths  and  one  known  recurrence. 

Prolapse  of  the  ureter  has  been  reported  by  Caile  in  a  child 
two  weeks  old.  There  are  nineteen  recorded  cases,  two  of  whom 
w^ere  operated  on,  with  one  death.  (Young.)  A  sac  which  was  sup- 
posed to  be  a  vesical  diverticulum  presented  at  the  urethral  orifice. 
It  was  found  to  be  a  prolapsed  ureter  dragged  down  by  a  papillo- 
matous growth. 

Two  cases  of  ureteral  cyst  caused  by  psorosperms  have  been  re- 
ported, one  by  Eve  ;  the  only  symptom  was  profuse  haematuria,  which 
was  not  attributed  to  the  cystic  formation. 


CHAPTER   XIV. 

INJURIES    AND    DISEASES    OF    THE    KIDNEYS. 

Surgical  Anatomy. — The  kidneys  are  situated  in  the  hypochon- 
driac region  on  either  side  of  the  vertebral  column  behind  the  perito- 
neum. (Fig.  170.)  The  right  kidney  is  a  little  lower  than  the  left 
(three-quarters  of  an  inch),  probably  because  of  the  superimposed 
liver.  The  left  kidney  extends  from  the  level  of  the  interval  between 
the  eleventh  and  twelfth  ribs,  near  the  spine,  to  the  level  of  the  third 
lumbar  spine.  Each  organ  is  inchned  forward  and  inward,  so  that 
their  upper  portions  converge.  The  outer  border  faces  upward  and 
backward,  the  inner  downward  and  forward. 

The  kidneys  are  fixed  in  position  by  a  series  of  short  blood- 
vessels, the  parietal  peritoneum,  the  pressure  of  the  abdominal  vis- 
cera, and  a  fibro-lipomatous  sheath  called  the  renal  fascia.  This 
fascia  is  formed  by  a  splitting  of  the  subperitoneal  connective  tissue, 
enclosing  the  kidney  in  a  pocket  and  passing  inward  as  a  single  layer 
to  cover  the  great  blood-vessels.  During  ftetal  life  this  investment  is 
purely  fibrous ;  later  there  is  an  abundant  deposit  of  fat,  to  which 
the  name  of  fatty  capsule  has  been  given.  The  deposit  of  fat  is  most 
marked  on  the  outer  borders  and  posterior  surfaces  of  the  kidneys. 
It  may  be  one  or  two  inches  in  thickness,  and  serves  to  fix  the  organs 
in  a  soft  nidus. 

The  kidney  of  average  size  is  four  and  a  half  inches  long,  two  and 
a  half  inches  broad,  and  one  and  a  half  inches  thick.  It  weighs 
about  four  and  a  half  ounces.  The  kidney  of  a  woman  is  about  half 
an  ounce  lighter. 

It  is  irregularly  oval  in  shape,  with  a  convex  outer  border  and 
a  concave  inner  border.  It  is  ordinarily  of  brownish-red  color,  but 
this  is  subject  to  marked  variations,  depending  upon  the  degree  of 
congestion  or  the  presence  of  degenerations.  It  is  fairly  firm  in  con- 
sistence. The  anterior  surface  of  the  kidney,  turned  forward  and 
shghtly  outward,  is  covered  by  peritoneum  in  its  upper  portion. 
The  upper  extremities  of  both  kidneys  are  capped  by  the  suprarenal 
bodies. 

The  liver  lies  in  front  of  the  upper  two-thirds  of  the  right  kidney, 
and  is  often  attached  to  it  by  a  peritoneal  fold  called  the  hepato- 
524' 


Fig.  170. 


~i  ^^, 


\    \ 


Position  and  relation  of  the  kidneys  and  other  retroperitoneal  structures. 


INJURIES   AND   DISEASES   OF   THE   KIDNEYS.  525 

renal  ligament.  Its  lower  third  is  in  relation  with  the  ascending 
colon,  which  lies  in  direct  contact  with  it,  the  beginning  of  the  trans- 
verse colon,  and  the  second  portion  of  the  duodenum,  which  de- 
scends vertically  along  the  inner  portion  of  the  anterior  surface, 
crossing  the  renal  vessels  and  their  bifurcations  at  a  right  angle.  The 
inferior  vena  cava  obliquely  crosses  the  extreme  upper  portion  of  the 
right  kidney.    (Testut.) 

The  anterior  surface  of  the  left  kidney  is  in  relation  with  the  tail 
of  the  pancreas,  which  rests  upon  its  upper  fourth,  with  the  spleen 
lying  above  and  externally,  and  the  stomach  below.  The  terminal 
portion  of  the  transverse  colon  and  the  upper  portion  of  the  descend- 
ing colon  lie  directly  in  contact  with  its  low^er  half  or  two-thirds,  con- 
nected to  it  by  loose  areolar  tissue,  unless  there  be  a  distinct  meso- 
colon. 

The  comparatively  flat  posterior  kidney  surface  faces  backward 
and  inward.  Behind  it  lie  the  diaphragm,  the  quadratus  lumborum 
muscle,  from  which  it  is  separated  by  the  anterior  layer  of  the  lumbar 
fascia,  and  the  intercostal  and  lumbar  nerves,  and  to  the  inner  side  the 
psoas  muscle.  Externally  it  extends  beyond  the  quadratus  lumborum 
muscle,  and  is  then  in  relation  with  the  transversalis.  The  posterior 
kidney  surface  is  entirely  free  from  peritoneal  investment,  except  in 
the  anomalous  condition  characterized  by  the  presence  of  a  meso- 
nephron. 

The  diaphragm  immediately  behind  the  upper  posterior  surface  of 
the  kidney  is  extremely  thin,  and  presents  a  triangular  opening, 
allowing  the  kidney  to  lie  in  almost  immediate  contact  with  the 
pleura.  This  opening  explains  the  frequency  with  which  abscesses 
burrow  into  the  pleura.  The  outer  convex  border  of  the  kidney  is  in 
relation  with  the  spleen  and  descending  colon  on  the  left  side,  the 
liver  on  the  right  side.  The  inner  concave  border,  resting  on  the 
psoas  muscles,  presents  a  fissure  termed  the  hilum,  into  which  pass 
the  blood-vessels  and  ureters  ;  it  is  about  two  inches  from  the  median 
line,  and  is  about  one  and  a  half  inches  in  depth.  The  important 
structures  coming  off  from  it  are  the  veins,  placed  anteriorly,  the 
arteries,  behind  the  veins,  and  the  pelves  and  ureters,  posteriorly. 
The  renal  arteries  and  veins  are  on  a  level  with  the  space  between 
the  spines  of  the  first  and  second  lumbar  vertebrae.  The  hilum  ex- 
tends to  a  considerable  depth  within  the  substance  of  the  kidney, 
forming  a  central  cavity  known  as  the  sinus. 

The  kidney  is  enclosed  in  a  proper  capsule  of  fibrous  tissue,  be- 
neath which  lies  an  investment  of  unstriped  muscles.  The  solid  part 
of  the  organ  is  composed  of  the  cortical  layer,  containing  the  Mai- 


526 


GENITO-UKllSrAKY   DISEASES   AND  SYPHILIS. 


pighian  glomeruli,  which  are  the  beginnings  of  the  uriniferous  tubules, 
and  the  medullary  layer,  containing  the  straight  and  spiral  portions  of 
the  uriniferous  tubules,  as  well  as  the  collecting  tubules.  These  col- 
lecting tubules  are  arranged  in  separate  pyramidal  masses,  the  pyra- 
mids of  Malpighi,  the  apices  of  which  form  papillae  projecting  into  the 
sinus.  (Fig.  184.)  They  are  separated  from  each  other  by  the  cor- 
tical substance,  which  envelops  them  on  all  sides,  except  in  the  region 
of  the  papillae.  The  papillae  project  into  the  calices  or  infundibula, 
which  are  the  small  diverticula  into  which  the  ureter  subdivides. 
When  the  ureter  reaches  the  sinus,  having  passed  in  by  the  hilum, 
it  dilates  into  a  funnel-shaped  sac,  called  the  pelvis.  From  this  sac 
pass  a  few  major  channels,  each  of  which  divides  into  several  smaller 
ones,  the  calices,  these  in  turn  terminating  about  the  openings  of  the 
papillae.  (Fig.  171.)  Usually  the  cahces  are  as  numerous  as  the 
papihae  ;  sometimes  two  papillEe  open  into  a  single  tubule.  The  num- 
ber of  calices  is  usually  from  eight  to  twelve.  Each  is  about  two- 
fifths  of  an  inch  long,  and  is  in  calibre  No.  6  to  No.  10  F,     Several 

of  these  small  canals  unite  to  form  a  series 
of  three  or  four  larger  canals,  which  open 
into  the  pelves  of  the  kidney.  (Fig.  171.) 
There  are  usually  three  of  these  large  branch- 
ings of  the  pelves, — an  upper,  a  median,  and 
a  lower.  They  vary  greatly  in  length  and 
calibre.  The  pelvis,  which  receives  the  urine 
from  the  calices,  is  about  an  inch  high  and 
not  quite  an  inch  wide,  and  runs  directly 
into  the  ureter.  (Fig.  171.)  Sometimes  the 
junction  of  these  two  channels  is  marked 
by  a  slight  constriction.  The  pelvis  is  placed 
within  the  sinus,  but  extends  upward  beyond 
the  limits  of  this  opening.  In  front  of  it  lie 
the  vessels ;  behind  it  lies  the  posterior  renal 
artery,  when  this  vessel  is  present.  The  por- 
tions which  extend  beyond  the  kidney  have 
the  peritoneum  and  the  fatty  capsule  in  front, 
the  psoas  muscle  posteriorly.  The  duodenum  is  in  relation  with  the 
anterior  surface  of  the  right  pelvis. 

The  arteries  of  the  kidneys  divide  into  four  or  five  branches, 
which  enter  the  hilum  and  lie  between  the  renal  vein  and  the  ureter. 
Within  the  sinus  the  branches  of  the  artery  run  beside  the  calices 
(infundibula)  and  are  embedded  in  fat.  The  right  renal  artery  is 
slightly  longer  than  the  left,  as  it  has  to  cross  the  vertebral  column ; 


Eenal  pelvis  dissected  from 
the  pyramids.  P,  pelvis ;  U, 
ureter.    (Henle.) 


.Ki 


INJURIES   AND   DISEASES   OF   THE   KIDNEYS.  527 

for  a  similar  reason  the  left  renal  vein  is  longer  than  the  right.  The 
renal  veins  leave  the  kidneys  at  the  hilum,  and,  passing  in  front  of  the 
renal  arteries,  empty  into  the  vena  cava  ;  the  spermatic  vein  joins  the 
renal  vein  on  the  left  side. 

The  blood-supply  to  the  kidneys  is  particularly  abundant.  The 
renal  artery  may  pass  as  a  single  vessel  to  the  hilum,  or  may  divide 
into  several  branches  before  reaching  this  point.  These  branches 
are  named,  according  to  their  distribution,  superior,  middle,  and  infe- 
rior. The  posterior  branch  passes  downw^ard  and  backward  to  enter 
the  hilum  behind  the  pelvis. 

The  veins  are  proportionally  as  numerous  and  large  as  the  arte- 
ries. In  the  sinus  there  are  a  number  of  branches,  usually  lying  in 
front  of  the  arteries  ;  these  fuse  into  the  renal  vein.  This  is  a  short, 
valveless  trunk  passing  to  the  vena  cava.  The  perinephric  veins  are 
large  and  numerous  and  communicate  with  the  blood-vessels  of  the 
kidney. 

The  lymphatics  pass  to  the  glands  of  the  lumbar  plexus  lying  near 
the  hilum.  The  nerves  are  abundant  and  supphed  with  ganglia  ;  they 
come  from  the  sympathetic  system.  In  the  stroma  of  the  kidney  are 
found  muscular  fibres,  especially  about  the  papillse. 

Hyrtl  has  demonstrated  that  about  two-thirds  of  all  kidneys  are 
vascularized  by  two  distinct  vascular  systems,  the  vessels  as  they  enter 
being  separated  from  each  other  at  the  renal  pelvis.  The  major  vas- 
cular tree  occupies  about  three-fifths  of  the  kidney,  usually  its  anterior 
portion,  and  the  remaining  posterior  two-fifths  is  vascularized  by  the 
.  minor  system.  Normally  these  two  vascular  systems  are  separated 
in  the  kidney  by  a  distance  of  about  two  millimetres.  Upon  disten- 
tion of  the  pelvis  and  calyces,  however,  this  separation  may  be  in- 
creased considerably.  At  the  plane  of  separation  no  large  vessels 
are  found  and  none  cross.  Upon  careful  examination  the  surface 
of  the  kidney  is  seen  to  be  made  up  of  a  number  of  irregular  areas 
about  the  size  of  the  end  of  the  thumb.  The  areas  represent  the 
bases  of  the  renal  pyramids.  They  are  surrounded  by  pale  lines 
representing  the  columns  of  Bertini  extending  up  between  the  pyra- 
mids and  forming  support  for  the  blood-vessels.  Sometimes  these 
pale  lines  are  not  seen,  but  in  their  place  may  be  distinguished  groups 
of  stellate  vessels.  These  small  white  lines  unite  a  little  anteriorly 
to  the  convex  border  of  the  kidney  into  a  longitudinal  slightly  depressed 
white  line,  appropriately  called  Brodel's  line,  which  represents  the  line 
of  division  between  the  anterior  and  posterior  rows  of  pyramids,  the 
connective  tissue  of  which  carries  the  largest  blood-vessels.  (Fig.  172.) 
At  a  distance  of  about  one  centimetre  away  from  this  white  line,  and 


528  GENITO-UKIlSrARY    DISEASES   AND   SYPHILIS. 

located  in  that  portion  of  the  kidney  corresponding  to  the"  surface, 
which,  as  determined  by  palpation  at  the  renal  hilum,  contains  the 
lesser  number  of  vessels  (usually  the  posterior  half),  is  located  the 
least  vascular  portion  of  the  organ.  This  avascular  plane  is  always 
parallel,  however,  with  Brodel's  white  line. 

Anomalies  of  the  Kidney. — The  kidneys  may  vary  from  nor- 
mal in  number,  size,  shape,  position,  attachment,  and  mobility. 

There  may  be  more  than  two  kidneys,  or  there  may  be  congenital 
absence  of  one  kidney.  This  latter  has  been  noticed  sufficiently 
often  to  warrant  the  suggestion  that  the  surgeon,  before  performing 
nephrectomy,  should  make  sure  of  the  presence  of  two  kidneys. 

Roberts  collected  twenty-nine  cases  of  solitary  kidney,  twenty- 
two  of  which  occurred  in  males  and  six  in  females.  The  sex  was  nat 
given  in  one  case.  In  sixteen  cases  the  left  kidney  was  absent,  in 
thirteen  the  right. 

Ballowitz  has  made  an  extensive  collection  of  cases  of  congenital 
absence  of  one  kidney.  He  found  that  the  deficiency  was  more  com- 
mon on  the  left  than  on  the  right  side,  and  that  the  single  kidney  was 
usually  normal  in  position  and  shape,  but  enlarged.  A  single  kidney 
has  sometimes  a  double  vascular  supply  and  two  ureters,  though 
showing  no  other  signs  of  fusion.  Morris  states  that  congenital  ab- 
sence of  one  kidney  can  be  expected  once  in  every  three  thousand 
nine  hundred  and  ninety-two  and  two-fifths  cases. 

The  kidney  may  be  congenitally  enlarged  ;  this  condition  is  usually 
associated  with  atrophy,  or  possibly  with  absence,  of  the  other  kidney, 
and  is  compensatory.  A  single  large  kidney  seems  to  be  perfectly 
competent  to  carry  on  the  functions  of  both  organs,  since  there  are 
many  autopsies  recorded  showing  that  the  bearers  of  this  malfor- 
mation have  lived  to  an  advanced  age  and  perished  of  other  diseases. 
Thus,  Conder  reports  one  such  case,  the  patient  dying  at  the  age  of 
seventy-two. 

Variations  in  shape  may  be  due  to  overgrowth  or  malformation  of 
neighboring  organs  or  structures.  Usually  these  are  true  growth- 
perversions,  and  they  may  assume  a  great  variety  of  forms. 

The  upper  extremities  of  the  kidney  may  be  joined  by  a  bridge 
over  the  abdominal  aorta  and  inferior  vena  cava,  the  organ  assuming 
a  horseshoe  shape  ;  this  connection  may  consist  of  true  kidney  struc- 
ture or  may  be  merely  a  band  of  connective  tissue.  It  may  closely 
simulate  tumor  of  the  stomach.  The  kidneys  may  be  fused  along 
their  whole  inner  surface,  forming  one  large  oval  or  rounded  organ, 
with  blood-vessels  and  excretory  ducts  attached  to  its  centre  or  pos- 
sibly to' one  side.     Fusion  usually  results  in  apparently  one  large  kid- 


INJURIES   AND   DISEASES    OP   THE    KIDNEYS.  529 

ney,  or  in  the  sigmoid  or  horseshoe  kidney  above  described.  Morris 
states  that  there  is  one  horseshoe  kidney  in  every  sixteen  hundred 
examinations.  Fusion  may  present  certain  bizarre  forms,  as  in  a 
case  reported  by  Gruber,  in  which  one  kidney  was  superimposed  upon 
the  other,  the  long  axes  of  the  organ  lying  at  right  angles  to  each 
other,  and  both  being  displaced  from  their  normal  position.  The 
kidney  may  also  be  found  extremely  lobulated.  This  condition  is 
normal  in  the  foetus.  When  it  persists  it  is  due  to  arrested  develop- 
ment. Double  ureter  and  multiple  arteries  and  veins  are  often  noted. 
Fused  kidneys  sometimes  reach  enormous  sizes. 

The  position  of  the  kidney  may  vary  from  the  normal  in  practi- 
cally any  direction  except  posteriorly.  The  kidney  may  lie  too  high, 
but  this  is  extremely  rare.  It  is  often  found  over  the  sacro-iliac  ar- 
ticulation, and  has  been  so  widely  displaced  that  it  has  been  found  in 
the  canal  of  Nuck.  Both  kidneys  may  lie  to  one  side  of  the  vertebral 
column,  either  about  their  normal  position  or  in  the  pelvis.  The  kid- 
ney may  be  tilted,  rotated,  or  turned  on  its  long  axis.  The  hilum 
may  look  forward,  outward,  downward,  upward,  or  backward ;  this 
malposition  may  be  associated  with  fusion. 

The  attachment  of  the  kidney  is  necessarily  anomalous  when  it  is 
fixed  in  a  faulty  position. 

The  anomahes  of  mobility  are  of  sufficient  surgical  importance  to 
receive  special  consideration.  The  other  growth-perversions  usually 
excite  no  symptoms,  and  are  of  importance  to  the  surgeon  prin- 
cipally because  they  may  cause  errors  in  diagnosis  and  treatment. 
Thus,  a  malformed  abnormally  placed  kidney  first  discovered  during 
the  course  of  abdominal  palpation  for  the  detection  of  the  cause  of 
obscure  gastro-intestinal  troubles  might  readily  lead  to  serious  error ; 
the  removal  of  a  diseased  kidney  would  necessarily  be  fatal  should 
this  happen  to  be  an  instance  of  solitary  kidney ;  an  attempted  ne- 
phrectomy on  a  fused  kidney  would  result  disastrously.  When  the 
kidney  is  fixed  in  a  faulty  position  it  usually  gives  rise  to  no  symp- 
toms. Morgagni,  however,  states  that  aortic  aneurism  was  caused 
by  the  pressure  of  horseshoe  kidney,  and  Neufville  records  the  case 
of  a  woman,  twenty-five  years  old,  previously  free  from  symptoms, 
who  in  consequence  of  the  sudden  congestion  of  a  horseshoe  kid- 
ney developed  thrombosis  of  the  large  veins,  which  was  followed  by 
death. 

The  only  operation  practicable  for  the  relief  of  symptoms  due  to 
a  kidney  congenitally  fixed  in  a  faulty  position  is  nephrectomy. 

Floating  kidney  is  a  congenital  anomaly  in  the  attachment  of 
the  organ.     The  floating  kidney  is  completely  enveloped  in  a  fold  of 

34 


530  GENITO-UPvINAEY   DISEASES   AND    SYPHILIS. 

the  peritoneum,  and  is  loosely  attached  to  the  posterior  abdominal 
wall  by  a  mesonephron :  hence  it  lies  within  the  peritoneal  cavity. 
The  condition  is  extremely  rare. 

A  differential  diagnosis  between  floating  and  movable  kidney  can- 
not be  made,  since  the  range  of  motion  is  sometimes  greater  in  the 
latter  condition  than  in  the  former. 

Movable  kidney  is  seven  times  as  frequent  in  women  as  in 
men.  The  causes  of  unnatural  mobility  are  such  as  lessen  the  intra- 
abdominal pressure,  or  mechanically  press  or  pull  the  kidney  from 
its  normal  recess.  Intra-abdominal  pressure  is  lessened  suddenly  by 
pregnancy,  more  gradually  by  emaciation  and  weakness  of  the  abdom- 
inal muscles.  The  kidney  is  thrust  or  dragged  from  the  paravertebral 
space  by  strain  or  traumatism,  lateral  curvature  of  the  spine,  the  action 
of  gravity,  particularly  in  cases  of  pathological  enlargement,  as  in 
hydronephrosis  and  calculus,  constriction  of  the  lower  ribs,  as  in  the 
case  of  tight  lacing,  and  the  weight  of  overlying  or  attached  organs, 
such  as  the  liver  or  the  hollow  viscera.  In  about  twenty  per  cent,  of 
cases  both  kidneys  are  abnormally  movable.  The  left  kidney  alone  is 
rarely  affected.  The  greater  frequency  with  which  the  right  kidney  is 
involved  (eighty  per  cent.)  is  explained  by  its  relation  to  the  liver  and 
the  greater  length  of  its  artery. 

Pathology. — The  vessels  and  fascia  are  elongated  and  thinned, 
the  ureter  often  partially  twisted  or  kinked,  and  the  renal  pelvis 
shows  dilatation  from  recurring  attacks  of  hydronephrosis.  The  kid- 
ney may  be  slightly  enlarged  from  passive  congestion,  or  may  present 
distinct  evidence  of  degeneration  from  retention.  Perirenal  and  peri- 
ureteral adhesions  may  form  from  the  same  cause.  The  peritoneum 
over  the  kidney  is  lax,  the  duodenum  may  be  elongated,  and  the  gall- 
bladder may  show  the  signs  of  biliary  retention  secondary  to  traction 
on  the  common  duct.  In  long-continued  cases  there  may  be  found 
the  phenomena  of  chronic  gastro-intestinal  catarrh  often  associated 
with  general  splanchnoptosis. 

Symptoms. — Aside  from  the  detection  of  the  tumor  by  palpation, 
the  cardinal  symptom  is  pain,  usually  referred  to  the  lumbar  region. 
This  may  amount  to  simply  a  dragging  and  wearing  sensation,  made 
worse  by  exertion  and  relieved  by  rest ;  or  it  may  be  paroxysmal, 
agonizing  in  type,  exactly  resembling  the  attacks  of  renal  colic  caused 
by  blocking  of  the  ureter  and  sudden  tension.  These  paroxysms 
recur  at  irregular  periods,  are  rather  sudden  in  onset,  and  often  follow 
fatigue  or  active  exertion.  Frequently  associated  with  this  pain  are 
distinct  gastro-intestinal  symptoms.  If  the  right  kidney  is  unduly 
movable,  it  may  partially  block  the  bile-duct  and  the  duodenum,  either 


INJUEIES   AND   DISEASES   OF   THE    KIDNEYS.  531 

by  direct  pressure  or  by  dragging,  thus  causing  hepatic  colic,  dilata- 
tion of  the  stomach,  and  symptoms  of  gastric  catarrh.  Wlien  the  left 
Iddney  is  movable,;the  same  partial  blocking  or  dragging  may  affect 
the  stomach  or  the  transverse  and  the  descending  colon,  thus  inter- 
fering with  intestinal  digestion. 

The  renal  colic  may  be  referred  to  the  lower  part  of  the  abdomen 
and  radiate  into  the  groin  and  down  the  thigh.  Shortly  there  develop 
great  tenderness  over  the  kidney  both  in  front  and  behind,  and  ab- 
dominal distention  and  tenderness  to  such  an  extent  as  to  make  renal 
palpation  difficult.  This  condition  may  persist  for  days,  but  usually 
subsides  in  a  few  hours. 

The  urine  is  usually  scanty  and  contains  blood.  Hypersecretion 
is  an  early  sign  of  relief  of  tension.  When  fever  develops,  the  diag- 
nosis may  be  exceedingly  difficult. 

Neurasthenia  is  commonly  associated  with  nephroptosis,  as  are 
flatulence,  constipation,  and  other  signs  of  gastro-intestinal  catarrh, 
possibly  reflex  in  origin,  probably  due  to  general  visceroptosis.  By 
pressure  against  the  vena  cava  and  particularly  against  the  ovarian 
vein  there  may  be  kept  up  a  passive  congestion  of  the  pelvic  organs, 
causing  menstrual  disturbances  and  predisposing  to  chronic  inflamma- 
tion.    (Goelet.) 

Morris  calls  attention  to  the  fact  that  movable  kidney  and  large 
gall-bladder  are  each  more  frequently  met  with  in  women  than  in 
men,  and  often  occur  in  the  same  person.  The  association  of  the 
two  states  is  explained  by  the  custom  of  wearing  corsets.  While  the 
downward  pressure  of  the  liver  induces  mobility  of  the  kidney,  the 
mobility  of  the  kidney  in  turn  acts  upon  the  gall-bladder  and  causes 
distention  by  dragging  upon  the  duodenum  and  the  bile-ducts,  thus 
obstructing  the  passage  of  the  bile.  The  same  mechanism  explains 
the  frequency  with  which  gastric  dilatation  and  symptoms  of  gastro- 
intestinal catarrh  are  associated  with  movable  kidney. 

Diagnosis. — This  is  based  on  the  history  of  a  sufficient  cause  for 
undue  mobility,  and  of  continuous  or  paroxysmal  pain,  often  with 
profuse  urination  following  the  paroxysms,  on  associated  symptoms 
of  gastro-intestinal  derangement,  and  on  the  finding  of  a  movable 
tumor  by  abdominal  palpation.  If  a  tumor  lying  in  the  hypochon- 
driac, the  Umbilical,  or  even  the  iliac  region  exhibits  the  characteristic 
depression  of  the  hilum,  if  the  pulsation  of  the  renal  artery  can  be 
recognized,  if  the  growth  on  manipulation  readily  recedes  into  the  loin, 
and  if  it  is  of  the  size  and  consistence  of  the  kidney,  the  diagnosis 
becomes  reasonably  certain. 

The  kidney  is  best  palpated  with  the  patient  in  the  dorsal  decubitus, 


532  gejS'ito-urinaky  diseases  and  syphilis. 

thighs  flexed,  head  and  shoulders  elevated,  and  the  trunk  slightly  in- 
clined towards  the  side  to  be  examined  by  a  thin  pillow  placed  under 
the  opposite  loin.  The  examiner  places  the  fingers  of  one  hand  just 
below  the  twelfth  rib,  those  of  the  other  below  the  costal  margin  in 
front  over  the  position  of  the  lower  pole  of  the  kidney,  and  by  gradu- 
ally increasing  bimanual  pressure  sinks  the  anterior  examining  fingers 
so  deeply  that  the  kidney  may  be  felt  in  its  expiratory  descent.  In 
the  majority  of  muscular,  well-nourished  patients  with  normally 
movable  kidneys  these  organs  cannot  be  felt  by  this  or  any  other 
method  of  renal  palpation.  In  weak  and  emaciated  women  the  kidney, 
even  though  but  normally  mobile,  can  usually  be  felt  on  the  right  side. 
When  the  kidney  descends  so  far  daring  inspiration  that  its  expiratory 
ascent  can  be  prevented  by  firmly  pressing  against  it  with  the  ex- 
amining fingers,  the  mobility  is  abnormal,  and  this  is  still  more  true 
when  the  entire  organ  can  be  pressed  and  held  downward  by  thrust- 
ing the  fingers  upward  and  backward  after  a  full  inspiration.  The 
gravity  of  renal  mobility  is,  however,  gauged  by  the  renal  changes  and 
the  symptoms  produced  by  it,  and  these  are  not  necessarily  propor- 
tionate to  the  range  of  motion. 

Malignant  omental  growths,  solid  tumors  of  the  ovaries,  growths 
of  the  abdominal  wall,  and  enlargement  of  the  spleen  can  usually  be 
readily  excluded,  partly  from  the  radical  difference  in  the  history, 
symptoms,  and  clinical  course,  mainly  by  careful  palpation,  fohowed 
by  colonic  air-distention  and  palpation  and  auscultatory  percussion. 
The  kidney  lies  behind  the  colon. 

Distention  of  the  gall-bladder  so  closely  simulates  floating  kidney 
that  differentiation  is  extremely  difficult. 

Both  may  be  characterized  by  gastro-intestinal  catarrh,  jaundice, 
colicky  attacks,  albuminuria  or  biliuria,  and  the  presence  of  a  tumor 
in  the  right  upper  abdominal  quadrant.  In  distinguishing  between 
these  two  afi'ections  the  history  is  of  cardinal  importance.  Enlarged 
gall-bladder  is  particularly  characterized  by  extreme  ease  of  palpation, 
constant  or  increasing  size,  the  slight  influence  of  posture  upon  its 
position,  free  respiratory  movement,  its  apparent  continuousness  with 
the  liver  substance  both  on  palpation  and  percussion,  and  its  limited 
range  of  mobility  under  manual  pressure.  Neither  can  it  be  made 
markedly  to  recede  to  the  loin.  Colicky  attacks  give  no  radiation 
downw^ard  and  are  not  attended  or  followed  by  haematuria.  Movable 
kidney  exhibits  limited  respiratory  motion,  but  a  free  range  incident  to 
palpation  or  body  position  ;  it  can  be  separated  from  the  liver,  is  at 
times  difficult  to  feel,  varies  greatly  in  size,  can  be  made  distinctly 
more  accessible  by  upward  lumbar  pressure,  and  recedes  to  the  loin. 


INJURIES   AND   DISEASES   OF    THE    KIDNEYS  533 

Colicky  attacks  are  associated  Avitli  pain  radiating  downward,  and  are 
attended  and  followed  by  hgematuria. 

Moreover,  the  pressure  upon  a  tender  kidney  produces  a  peculiar 
sickening  much  like  that  incident  to  testicular  trauma.  When  the 
surgeon  is  in  douht,  the  condition  is  usually  movable  kidney. 

The  two  conditions  may  co-exist.  In  this  case  careful  palpation 
will  enable  the  surgeon  to  separate  one  tumor  from  the  other. 

The  distinction  between  movable  kidney  and  calculus  is  readily 
made  when  each  has  developed  typically ;  when  the  mobility  of  the 
kidney,  though  sufficient  to  cause  blocking  of  the  ureters,  is  so  slight 
that  it  cannot  be  detected  by  palpation,  the  differential  diagnosis  is 
made  possible  by  the  skiagraph. 

Omental  or  mesenteric  infiltrations  or  pyloric  carcinoma  cause 
neither  the  colicky  paroxysms  nor  the  urinary  phenomena  of  float- 
ing kidney. 

Prognosis. — The  ultimate  prognosis  as  far  as  the  kidney  itself  is 
concerned  is  bad  in  all  cases  accompanied  by  distinct  renal  symptoms 
and  pathological  conditions  of  the  urine.  When  the  pain  is  slight, 
or,  if  severe  and  paroxysmal,  when  it  recurs  at  long  intervals,  lasts 
but  a  short  time  and  is  relieved  promptly  by  position  and  rest,  and 
when  symptoms  are  not  steadily  increasing  in  severity,  the  outlook  is 
favorable,  and  the  patient  can  probably  be  kept  comfortable  by  the 
wearing  of  a  proper  appliance.  Severe,  long-lasting  pain,  of  frequent 
occurrence,  necessarily  imphes  ultimate  disorganization  of  the  secret- 
ing substance  of  the  kidney,  since  this  pain  is  due  to  tension  or  twist- 
ing of  the  pedicle,  either  of  these  conditions  causing  profound  altera- 
tions in  nutrition. 

Pronounced  mobility  may  be  unattended  by  renal  symptoms  or 
alterations  in  the  urine,  and  under  such  circumstances  does  no  harm. 
An  amount  of  motion  which  cannot  be  detected  by  the  most  careful 
palpation  may  be  sufficient  to  cause  pronounced  symptoms.  Sooner 
or  later  a  floating  and  degenerating  kidney  profoundly  alters  general 
nutrition,  often  producing  a  condition  of  melancholia  or  neurasthenia. 
The  gastro-intestinal  symptoms  when  once  well  developed  are  com- 
monly progressive  unless  the  mechanical  cause  is  removed. 

Debove  cured  a  case  of  muco-membranous  enteritis  by  anchoring 
an  intermittently  hydronephrotic  kidney,  and  has  shown  that  chronic 
hydronephrosis  of  one  side  may  cause  interstitial  nephritis  of  the  other. 

Treatment. — This  is  either  palliative  or  radical. 

Palliative  Treatment. — The  condition  can  be  palliated,  often  cured, 
by  a  rest  cure  of  five  weeks  in  the  dorsal  decubitus,  with  particular 
attention  paid  to  abdominal  massage,  correction  of  slight  lateral  spinal 


534 


GENITO-URIiSrAPvY   i)ISEASES   AISTD   SYPHILIS. 


curvature,  exercises  calculated  to  develop  the  abdominal  muscles,  and 
the  application  of  a  corset,  so  planned  that  the  abdominal  parietes 
are  evenly  supported  and  enteroptosis  is  prevented.  The  straight- 
front  corsets  are  well  adapted  to  this  purpose.  The  corset  must 
be  accurately  fitted  by  measurements  taken  with  the  patient  in 
dorsal  decubitus  with  elevated  hips,  and  should  always  be  laced  on 
with  the  patient  in  this  position  (Gallant).  Its  greatest  pressure 
should  be  exerted  upon  the  lower  abdominal  segment,  the  front 
being  carried  down  as  far  as  possible.  Moderate  support  should  be 
afforded  at  the  waist-line,  and  great  care  should  be  taken  to  see 
that  there  is  no  pressure  above  this  line. 

Fig.  173. 


Proper  method  of  applying  corset  for  movable  kidney.    (Dr.  Ernest  A.  Gallant.) 

Patients  must  be  cautioned  against  violent  exertion  or  straining 
of  any  kind.  The  bowels  must  be  kept  soluble,  since  the  muscular 
effort  required  to  evacuate  hardened  faeces  tends  to  displace  the  kid- 
ney. Digestive  disturbances  should  be  corrected  by  diet  and  proper 
medication,  and  due  attention  should  be  given  to  general  hygiene. 
The  acquisition  of  abundance  of  fat  is  much  to  be  desired.  When  in 
spite  of  this  treatment  the  symptoms  of  obstruction  persist,  nephror- 
rhaphy  is  indicated. 

When  sudden  violent  pain  shows  that  the  pelvis  or  ureter  is 
blocked,  an  attempt  should  at  once  be  made  to  place  the  kidney  in  its 
proper  position.     In  the  intervals  of  paroxysmal  pain  this  is  usually 


INJUKIES    AND   DISEASES   OF    THE    KIDNEYS.  535 

accomplished  without  difficulty.  Patients  suffering  from  movable  kid- 
ney are  apt  to  be  thin,  with  lax  abdominal  walls  :  hence  the  kidney 
can  be  distinctly  palpated,  and  pressure  can  be  so  exerted  that  it  will 
slip  readily  into  its  normal  place. 

During  the  attacks  of  pain,  especially  when  these  are  compli- 
cated by  symptoms  of  local  peritonitis,  this  reposition  may  be  difficult. 
Nevertheless  it  should  always  be  attempted,  ether  being  given  if 
necessary.  No  force  should  be  used,  since  the  surgeon  is  to  a  cer- 
tain extent  acting  blindly.  The  kidney  should  be  seized,  outlined, 
mobilized,  and  restored  to  its  normal  position  if  possible.  Severe 
pain  is  quieted  by  a  hot  bath  and  the  use  of  hypodermics  of  mor- 
phine, repeated  as  often  as  may  be  necessary.  Hot  compresses 
should  be  applied  over  the  abdominal  surface  when  tympany  de- 
velops. With  the  subsidence  of  acute  symptoms  renewed  efforts 
should  be  made  to  replace  the  kidney.  If  these  efforts  fail,  it  will  be 
because  of  inflammatory  adhesions. 

Operative  Treatment. — This  has  for  its  end  fastening  the  kidney  in 
its  normal  position  by  sutures  and  adhesions.  It  is  indicated  when 
in  association  with  an  abnormal  degree  of  mobility  the  symptoms  are 
distinctly  renal,  and  do  not  yield  to  rest,  hygiene,  and  a  proper  abdom- 
inal support. 

The  patient  is  placed  on  the  operating-table,  lying  nearly  in  the  ven- 
tral decubitus,  with  the  side  corresponding  to  the  floating  kidney  up. 
The  head  is  turned  to  one  side,  the  forearm  brought  in  front  of  the 
chest,  the  body  slightly  flexed,  and  the  thighs  bent.  Beneath  the  ilio- 
costal space  of  the  sound  side  is  placed  a  sand-pillow  or  roll  of  mate- 
rial about  the  size  of  a  man's  thigh  ;  this  causes  slight  lateral  curvature 
of  the  spine  and  increases  the  iho-costal  space.     (Fig.  181,  page  561.) 

The  instruments  required  are  a  strong  scalpel  of  medium  size,  dis- 
secting forceps,  toothed  forceps,  half  a  dozen  hsemostatic  forceps,  two 
broad  right-angled  retractors,  two  large  curved  needles,  and  a  grooved 
director.  Two  assistants  are  required.  The  twelfth  rib  having  been 
clearly  outlined,  an  incision  is  made,  beginning  half  an  inch  below  this 
rib  and  about  the  outer  border  of  the  erector  spinse  muscle  (two 
inches  from  the  middle  line),  and  running  downward  and  forward  to- 
wards the  iliac  crest.  This  incision  should  be  three  or  four  inches 
long.  It  divides  the  skin  and  superficial  fascia ;  the  latissimus  dorsi 
should  be  retracted;  the  external  and  the  internal  oblique  muscles 
should,  as  far  as  practicable,  be  split  in  the  direction  of  their  fibres ; 
the  posterior  and  anterior  layers  of  the  lumbar  fascia  and  the  trans- 
versalis  fascia  are  divided,  exposing  the  fibro-adipose  capsule  of  the 
kidney.     The  retractors  are  passed  down  to  the  perinephric  fat,  and 


536 


GENITO-UIUNAEY   DISEASES   AND    Sl^PHILIS. 


the  wound  is  spread  open  as  widely  as  possible.  While  an  assistant 
presses  the  kidney  upward  and  backward  into  its  normal  position  the 
fatty  capsule  is  seized  in  the  rat-tooth  forceps  and  opened  with  a  knife, 
and  the  edges  of  the  opening  are  seized  in  haemostats,  after  which  the 
dorsal  surface  of  the  kidney  is  freely  exposed.  The  sutures  of  chromi- 
cized  or  iodized  No.  2  catgut  are  inserted  one  in  the  postero-convex 
border,  one  near  the  upper  pole,  the  other  well  below  the  middle, 
thus  preventing  inward  or  forward  rotation.  Each  is  passed  from 
above  downward  for  half  an  inch  beneath  the  capsule,  then  from 
below  upward  the  needle  entering  a  quarter  of  an  inch  from  its  pre- 
vious point  of  exit  for  half  an  inch,  coming  out  near  the  point  of 


Fig.  174. 


Sustaining  sutures  for  fixing  the  kidney.    (Brodel.) 

original  entrance.  Brodel  has  demonstrated  that  thus  placed  the  sutures 
stand  three  times  as  much  traction  as  by  the  older  methods,  and 
are  hence  much  less  likely  to  tear  out  from  the  effort  of  cough- 
ing or  vomiting.  These  sutures  are  carried  through  the  fatty  cap- 
sule, transversalis  fascia,  and  deep  muscles,  and  are  tied  down 
after  the  incision  through  the  muscles  and  fascia  is  firmly  closed  by 
a  sufficient  number  of  buried  catgut  sutures.  No  drainage  is  used. 
The  patient  is  kept  in  the  dorsal  decubitus  under  rest  cure  for  five 
weeks. 

After  operation  the  patient  should  lie  in  the  dorsal  decubitus  for  at 
least  five  weeks,  should  wear  a  supporting  bandage  or  straight-front 


INJURIES   AND   DISEASES    OF    THE    KIDNEYS.  537 

corset  for  six  months,  and  should  avoid  violent  strain  or  muscular 
effort  for  a  much  longer  period.  The  mortality  of  the  various  tbrms 
of  nephrorrhaphy  is  less  than  two  per  cent.  Mechanical  cure  is  the 
rule,  and  in  the  majority  of  properly  selected  cases  complete  relief 
from  symptoms  may  be  expected. 

When  the  operation  of  nephrorrhaphy  has  been  carefully  per- 
formed twice  and  has  been  unsuccessful,  or  when  it  is  impossible  to 
place  the  kidney  in  the  proper  position,  and  symptoms  are  severe  and 
progressive,  nephrectomy  is  a  justifiable  operation. 

Newman  gives  the  mortality  of  this  operation  for  movable  kidney 
as  thirty  per  cent.  The  operation  is  not  to  be  considered  unless  there 
is  absolute  certainty  as  to  the  existence  of  a  sound  kidney  which  is 
able  to  carry  on  the  work  of  elimination.  For  the  purpose  of  total 
removal  the  kidney  may  be  reached  from  in  front  through  the  hnea 
alba  or  the  linea  semilunaris,  or  from  the  lumbar  region,  as  in  the 
operation  of  nephrorrhaphy.  When  ureteral  catheterization  has  failed 
to  demonstrate  the  condition  of  the  other  kidney,  or  even  its  presence, 
the  abdominal  operation  is  to  be  preferred. 

The  treatment  just  given  for  movable  kidney  is  applicable  to 
floating  kidney ;  in  operating,  however,  the  peritoneal  cavity  must 
be  opened  unless  the  two  layers  of  the  mesonephron  are  widely 
separated. 

INJURIES   OF  THE   KIDNEY. 

In  accordance  with  the  customary  surgical  classification,  injuries 
of  the  kidney  may  be  considered  under  the  general  headings  con- 
tusions and  wounds.  In  contusions  the  injury  to  the  kidney  is  sub- 
parietal,  no  externa,!  wound  leading  down  to  this  organ.  In  wound 
of  the  kidney  there  is  solution  in  the  continuity  of  the  soft  .parts 
leading  to  the  seat  of  injury. 

Contusion  of  the  Kidney. — The  cause  of  contusion  may  be 
direct  or  indirect  violence. 

Direct  violence  is  instanced  by  kicks,  blows,  or  crushing  pressure, 
as  from  the  wheels  of  a  cart,  applied  to  the  lumbar  region.  Except 
in  cases  complicated  by  fractured  bones  and  injury  to  other  impor- 
tant viscera,  the  vulnerating  body  is  usually  small,  or  at  least  narrow, 
since  there  is  a  comparatively  small  unprotected  space  through  which 
it  can  act  directly  on  the  kidney,  particularly  when  it  is  applied  sud- 
denly and  unexpectedly,  thus  surprising  the  parietes  when  they  are 
relaxed,  and  when  the  ilio-costal  space  is  broadest.  Direct  violence 
usually  involves  the  right  kidneys  of  men. 

Indirect  violence  is  instanced  by  contortions  or  flexions  of  the 
trunk,  or  by  violent  jarring  from  a  fall. 


538  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

The  injury  may  vary  in  severity  from  moderate  contusion  to  lacera- 
tion, or  to  complete  disintegration. 

Tuffier  recognizes  four  degrees  of  injury.  The  first  degree  is  char- 
acterized by  subcapsular  ecchymoses.  When  the  violence  has  been 
more  marked  (second  degree),  intrarenal  blood  extravasations  are 
found,  most  marked  and  constant  at  the  base  of  the  pyramids.  In 
the  third  degree  the  capsule  is  ruptured  ;  there  is  extrarenal  hemor- 
rhage, and  deep,  multiple,  stellate  fissures  of  the  kidney-substance  are 
produced,  most  pronounced  about  the  hilum ;  sometimes  they  com- 
pletely divide  the  kidney.  Finally,  the  organ  may  be  reduced  to  a 
pulpy  detritus  ;  exceptionally  a  large  branch  of  the  renal  artery  may 
be  ruptured.  Bleeding  within  the  kidney  is  rarely  profuse.  Extra- 
renal hemorrhage  may,  however,  be  fatal. 

Severe  contusion  of  the  kidney  is  often  complicated  by  rupture  of 
the  liver,  the  spleen,  the  intestines,  and  the  lungs;  the  peritoneum 
lying  in  front  of  the  kidney  is  likely  to  be  torn,  particularly  in  children, 
in  whom  the  fatty  envelope  of  the  kidney  is  wanting.  Mackin  has 
shown  that  injuries  to  the  kidneys  are  the  most  frequent  visceral 
lesions  of  abdominal  contusions,  and  that,  as  a  rule,  other  viscera  are 
not  involved.     The  injury  is  usually  on  the  right  side. 

Symptoms. — Symptoms  of  contusion  of  the  kidney  are  shock,  pain, 
haematuria,  diminution  in  the  quantity  of  urine  passed,  and  the  forma- 
tion of  a  tumor. 

Shock  is  usually  pronounced,  particularly  when  the  kidney  is 
lacerated  or  completely  ruptured.  It  is,  however,  not  always  a  reli- 
able symptom.  Thus,  Rayer  quotes  an  instance  in  which  a  patient, 
having  struck  against  an  angular  projection,  was  so  little  affected 
by  the  accident  that  he  continued  his  occupation.  He  died  some 
weeks  later,  and  post-mortem  examination  showed  rupture  of  the 
kidney.  In  cases  of  slight  contusion  characterized  by  superficial  or 
parenchymatous  ecchymoses,  shock  may  be  entirely  wanting. 

Pain  is  usually  the  first  symptom  of  contused  kidney.  It  varies 
in  intensity  from  a  sickening,  weakening  ache  to  an  unbearable  an- 
guish comparable  to  that  characteristic  of  nephritic  colic.  It  is  felt 
in  the  lumbar  region,  but  usually  radiates  down  the  ureters,  and  is 
often  accompanied  by  retraction  of  the  testis.  It  may  be  transitory, 
or  may  last  for  several  days.  It  is  often  accompanied  by  nausea, 
vomiting,  and  tympany.  When  it  persists  it  is  liable  to  be  paroxys- 
mal, and  is  then  probably  due  to  temporary  ureteral  obstruction  and 
kidney  tension,  caused  by  the  passage  of  clots  through  the  ureter. 

Haematuria  may  follow  an  injury  to  the  abdominal  wall,  and  does 
not  necessarily  indicate  that  the  substance  of  the  kidney  has  been 


INJURIES    AND    DISEASES    OF   THE    KIDNEYS.  539 

bruised.  When  it  is  easily  excited  it  is  usually  a  sign  of  a  masked 
lesion  of  the  kidney,  such  as  encysted  calculus,  which  may  have  been 
dislodged,  or  a  pre-existing  thrombus,  or  tumor,  or  renal  tuberculosis. 

When  the  kidney  is  contused  hsematuria  is  practicahy  constant, 
and  is  often  profuse.  Blood  may  appear  in  the  urine,  either  imme- 
diately after  the  injury  or  not  for  several  hours ;  it  may  persist  for 
several  days,  or  may  be  abundant  for  a  day  or  two  and  then  suddenly 
cease,  because  the  ureter  is  blocked  by  a  clot.  In  this  case  there 
will  probably  be  severe  renal  colic ;  when  the  clot  is  passed  pain  will 
cease,  and  there  will  be  recurrence  of  blood  in  the  urine.  The 
quantity  of  blood  passed  is,  as  a  rule,  proportionate  to  the  severity 
of  the  lesion.  If,  however,  the  ureter  is  torn  across,  or  if  it  becomes 
at  once  blocked  by  a  large  clot,  the  urine  may  remain  perfectly  clear, 
even  though  the  kidney  is  pulpified. 

The  blood  usually  disappears  within  a  week.  Sometimes  it  per- 
sists for  several  weeks,  and  exceptionally,  instead  of  growing  less, 
it  steadily  augments  in  quantity  until  the  patient  perishes  of  anaemia. 
The  clot,  in  place  of  passing  through  the  ureter,  may  permanently 
occlude  it,  causing  hydronephrosis  or  atrophy  of  the  kidney.  Butler 
reports  a  case  in  which  the  left  ureter  became  thus  occluded  the 
fourth  day  after  an  injury.  This  was  followed  by  total  suppression 
of  urine  for  fourteen  days,  and  ended  in  death.  The  right  kidney 
was  found  to  be  cystic  and  atrophic.  Frequent  and  painful  urination 
is  not  an  uncommon  symptom  when  blood  is  passing  through  the 
ureter  in  the  shape  of  clots  which  act  as  foreign  bodies  in  the  bladder ; 
often  there  is  retention  of  urine. 

Alteration  in  the  quantity  of  urine  secreted  constitutes  an  impor- 
tant symptom  of  kidney  contusion.  Urine  may  be  totally  suppressed 
immediately  after  the  injury,  or  this  suppression  may  not  develop  until 
some  hours  later.     It  is  often  followed  by  compensatory  polyuria. 

The  formation  of  a  tumor  is  primarily  due  to  hemorrhage ;  even 
though  this  be  subcapsular  the  enlargement  may  be  palpable.  When 
the  capsule  is  ruptured  and  there  is  free  bleeding  into  the  perinephric 
tissues,  there  is  quickly  formed  an  extensive  and  increasing  area  of 
dulness  and  swelling  in  the  lumbar  and  possibly  in  the  iliac  region. 
The  hemorrhage  may  be  so  rapid  and  profuse  that  marked  consti- 
tutional symptoms  develop, — i.e.,  feebleness  and  rapidity  of  the  pulse, 
pallor,  coldness  of  the  extremities,  and  collapse.  Tumor  of  the  loin 
was  present  in  one  hundred  and  eleven  of  Watson's  four  hundred  and 
eighty-six  cases.  It  was  usually  due  to  perinephric  abscess,  hydro- 
nephrosis, or  pyonephrosis  ;  thirty-nine  cases  having  been  caused  by 
perirenal  bleeding  and  four  by  haematonephrosis. 


540  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

Rayer  states  that  in  intrarenal  bleeding  the  swehing  is  sharply  cir- 
cumscribed, forms  later  and  more  slowly  than  in  perirenal  extrava- 
sation, and  is  rounded  and  movable.  Perirenal  extravasation  is 
diffuse.  Satisfactory  palpation  is  in  these  cases  often  impossible,, 
because  of  the  exquisite  sensitiveness  of  the  kidney  and  the  regions 
about  it.  When  the  hemorrhage  is  confined  to  the  pelvis  of  the  kidney 
and  the  ureter  it  seldom  forms  an  appreciable  tumor  unless  it  finds  its 
way  up  under  the  fibrous  capsule  because  of  such  extensive  laceration 
of  the  renal  tissue  as  to  render  this  capsule  easily  separable.  Usually 
bleeding  occurs  immediately,  but  Rayer  reports  a  case  of  hsematoma 
which  was  not  observed  until  six  weeks  after  the  injury. 

Rupture  may  take  place  into  the  peritoneal  cavity,  a  complication 
which  is  generally  fatal.  Intraperitoneal  bleeding  is  characterized  by 
the  rapid  development  of  tympanites  and  signs  of  peritonitis,  together 
with  symptoms  of  internal  hemorrhage. 

A  perirenal  blood  effusion  is  sometimes  evacuated  with  the  urine^ 
this  occurring,  according  to  Tuffier  and  Levi,  towards  the  end  of  the 
second  week  following  the  injury  and  being  characterized  by  the  sub- 
sidence of  the  tumor  and  the  reappearance  of  blood  in  the  urine, 
which  may  have  been  clear  for  several  days. 

Diagnosis. — The  diagnosis  of  contusion  of  the  kidney  is  based  on 
— (1)  The  form  of  traumatism  :  thus,  the  sharp  corner  of  a  table 
striking  the  side  between  the  pelvis  and  the  costal  border,  a  kick  or 
a  blow  delivered  from  before  backward  below  the  ribs  and  over  the 
region  of  the  kidneys,  a  crushing  force  fracturing  the  lower  ribs,  or 
extreme  flexion  or  extension  of  the  body,  would  be  sufficient  cause 
for  kidney-rupture.  (2)  The  immediate  appearance  of  blood  in  the 
urine,  in  the  absence  of  bladder-lesion.  The  rare  cases  in  which 
such  bleeding  follows  simple  traumatism  of  the  back  may  be  dis- 
regarded. If  the  bleeding  is  profuse  and  exhibits  worm-like  clots, 
it  offers  the  characteristics  of  traumatic  renal  hemorrhage.  (3) 
Marked  diminution  in  the  quantity  of  urine  secreted,  or  complete 
suppression  of  the  secretion.  This  symptom  may  follow  any  severe 
traumatism  to  the  abdominal  contents.  It  may  be  of  value  when 
associated  with  hemorrhage.  (4)  The  rapid  formation  of  a  lumbar 
swelling  associated  with  extreme  tenderness.  (5)  Intense  pain  radi- 
ating in  the  direction  of  the  ureter  and  accompanied  by  retraction  of 
the  testes.  (6)  Subcutaneous  ecchymoses  developing  several  days 
after  the  injury.  These  may  appear  in  the  loin,  or  may  be  found  in 
the  inguinal  region.  Dumesnil  has  particularly  insisted  upon  the 
importance  of  this  symptom,  and  states  that  it  is  indicative  of  serious 
injury.  • 


INJURIES   AND    DISEASES    OF   THE    KIDNEYS.  54I 

This  group  of  symptoms  is  diagnostic.  It  has  been  shown,  how- 
ever, that  they  are  often  not  associated ;  thus,  haematuria,  the  most 
characteristic  symptom,  may  be  absent ;  but  if  the  kidney-lesion  is 
extensive  a  haematoma  is  certain  to  form.  When  the  peritoneum  is 
ruptured,  and  extensive  bleeding  takes  place  into  the  general  peri- 
toneal cavity,  the  only  symptoms  pointing  to  injury  of  the  kidney  will 
be  haematuria  and  possibly  characteristic  pain  ;  shock  and  peritonitis 
quickly  mask  the  other  symptoms  indicative  of  kidney-lesion.  Abdom- 
inal symptoms  are  occasionally  noted,  however,  in  the  absence  of  intra- 
peritoneal rupture  ;  they  occurred  in  eighteen  of  Watson's  cases.  They 
become  marked  immediately  or  very  soon  after  the  accident,  are  of 
relatively  short  duration,  and  are  not  progressively  severe.  The  one 
sure  sign  of  intraperitoneal  rupture  of  the  kidney  is  free  fluid  in  the 
peritoneal  cavity,  as  indicated  by  non-circumscribed,  generally  bilateral, 
movable  dulness.  In  cases  uncomplicated  by  peritoneal  rupture  the 
area  of  dulness  is  unilateral,  and  is  more  or  less  circumscribed, 
extending  three  or  four  fingers'  breadth  below  the  costal  arch  and  as 
far  forward  as  the  mid-clavicular  line.  Upon  its  progressive  rapid 
increase  in  size  often  depends  the  advisability  of  operative  interfer- 
ence. Progressive,  but  slow,  increase  in  size  of  this  area  of  dulness 
occurs  with  the  development  of  perinephric  abscess  (sixteen  of  Wat- 
son's cases),  and  with  hydronephrosis  (eight  of  Watson's  cases). 

Ruptured  bladder  is  characterized  by  pain  in  the  hypogastrium 
with  vesical  tenesmus  and  the  passage  of  a  small  amount  of  bloody 
urine,  or  inability  to  pass  any  urine  and  the  finding  of  an  empty 
bladder,    (See  page  408.) 

Prognosis. — Most  cases  of  contusions  of  the  kidney  of  the  first 
degree,  characterized  by  subcapsular  ecchymosis,  heal  spontaneously 
apparently  without  sequelae,  and  probably  this  is  true  of  the  cases 
exhibiting  disseminated  extravasations  into  the  substance  of  the  kid- 
ney. When  the  organ  is  extensively  ruptured  the  prognosis  is  grave. 
According  to  Morris,  the  two  chief  conditions  upon  which  recovery 
depends  are  the  escape  of  the  peritoneum  and  of  the  large  branches 
of  the  renal  artery  and  vein ;  if  a  large  branch  of  the  renal  artery  be 
torn,  and  death  does  not  follow  from  bleeding,  the  gradually  increasing 
hemorrhage  is  likely  to  lead  by  pressure  to  sloughing  of  the  perito- 
neum, even  though  that  membrane  may  have  escaped  the  original 
injury.  Recovery  may  follow  extensive  laceration  or  even  complete 
pulpification  of  the  kidney.  This,  however,  is  rare.  Duplay  and 
Rectus  state  that  in  simple  lacerations  the  mortality  is  forty-three  per 
cent. ;  in  laceration  complicated  by  rupture  of  other  organs  or  frac- 
tures of  the  neighboring  bones  the  mortality  is  eighty-seven  per  cent. 


542  GENITO-TJEINAEY   DISEASES   AND   SYPHILIS. 

Complications. — Complications  which  are  immediately  threatening 
to  life  after  rupture  of  the  kidney  are  shock,  hemorrhage,  and  anuria. 
Later  the  chief  danger  is  from  sepsis.  The  majority  of  contusions 
escape  this  complication.  The  conditions  are,  however,  so  favorable 
for  its  development  that  it  is  one  of  the  most  frequent  causes  of  death 
in  patients  who  survive  the  immediate  effects  of  the  injury.  A  com- 
mon, cause  of  infection  is  the  passage  of  a  catheter.  If  the  kidney 
capsule  has  been  ruptured  suppuration  extends  into  the  perinephric 
tissues.  Chills,  fever,  increasing  pain  and  tenderness  in  the  lumbar 
region,  and  marked  diminution  in  the  quantity  of  urine  secreted, 
should  suggest  the  probability  of  infection  and  should  lead  to  lumbar 
incision.     Death  may  occur  from  secondary  hemorrhage. 

Cystitis  is  a  complication  of  great  gravity  ;  it  often  follows  uncleanly 
catheterization  and  may  even  lead  to  infection  of  the  sound  kidney. 
Hydronephrosis  may  develop  as  a  consequence  of  the  blocking  of  the 
ureter  by  a  clot ;  this,  in  case  of  infection,  becomes  converted  into 
pyonephrosis.  Traumatic  peritonitis  from  the  escape  of  blood  and 
urine  into  the  peritoneal  cavity,  and  thrombosis  of  the  renal  vessels, 
are  sequelae  that  have  been  frequently  fatal.  The  kidney  may  be  dis- 
placed from  its  normal  position,  and  thereafter  may  rpmain  preter- 
naturally  movable.  As  a  remote  sequel  of  traumatism  various  forms 
of  Bright's  disease  may  develop.  Exceptionally  the  blood-clots  form 
nuclei  for  renal  stones.  Ebstein  holds  that  contusion  is  a  predis- 
posing factor  in  the  development  of  renal  tumors. 

Treatment. — Shock,  if  pronounced,  is  treated  in  accordance  with 
general  surgical  principles.  When  there  is  reason  to  believe  that  the 
kidney  is  bruised,  the  patient  is  put  to  bed,  is  kept  absolutely  quiet,  and 
is  given  hypodermic  injections  of  morphine  for  the  relief  of  pain  if  this 
is  severe.  When  the  hemorrhage  is  profuse,  ergotin  is  given  hypo- 
dermically,  an  ice-bag  is  applied  to  the  lumbar  region,  and  the  side  is 
strapped  with  long  strips  of  adhesive  plaster,  applied  as  for  fractured 
ribs.  In  addition  to  the  straps  a  broad  roller  bandage  is  applied ;  this 
secures  a  compress  of  gauze  or  cotton  over  the  kidney.  It  is  unwise 
to  give  either  medicine  or  food  by  the  mouth  for  the  first  few  hours, 
since  the  patient  is  likely  to  vomit,  and  this  may  start  a  bleeding 
which  has  already  stopped.  The  straining  and  retching  which  occur 
even  when  the  stomach  is  empty  are  best  relieved  by  sufficient  doses 
of  morphine.  Thirst  may  be  appeased  by  rectal  injections  of  normal 
salt  solution,  a  pint  at  a  time,  at  blood  heat. 

A  fairly  well-nourished  man  can  subsist  perfectly  well  for  three  to 
five  days  without  nourishment  of  any  kind,  and  it  is  wise  to  withhold 
even  liquid  food  until  the  stomach  is  retentive.     For  three  weeks  at 


INJUEIES   AND   DISEASES   OF    THE    KIDNEYS.  543 

least  after  suspected  injuries  of  the  kidney  the  diet  should  be  Uquid, 
and  the  intestinal  evacuations  should  be  so  regulated  as  to  be  ac- 
complished without  straining.  This  may  require  the  daily  adminis- 
tration of  enemata.  Morris  has  seen  hemorrhage  brought  on  more 
than  two  weeks  after  the  injury  by  the  passage  of  sohd  fgecal  matter 
through  the  colon,  thereby  giving  rise  to  pressure  against  the  kidney. 
Coughing,  sneezing,  forced  efforts  at  micturition,  sitting  up,  any  act 
which  may  suddenly  change  the  conditions  of  intra-abdominal  press- 
ure, should  be  avoided.  As  soon  as  the  stomach  becomes  retentive, 
salol  and  boric  acid  should  be  given  by  the  mouth  for  the  purpose  of 
rendering  the  u-rine  slightly  antiseptic,  and  the  patient  should  drink 
an  alkaline  water  freely,  since  the  lower  the  specific  gravity  of  the 
urine  the  less  the  tendency  towards  the  formation  of  tough  clots. 

Should  retention  of  urine  develop  because  of  clots  blocking  the 
urethra,  an  effort  should  be  made  to  relieve  this  condition  by  a  hot 
bath.  This  failing,  the  suction  catheter  or  the  litholapaxy  tube  and 
evacuator  may  be  used.  These  instruments  must  be  employed  with 
minute  attention  to  the  antiseptic  precautions  already  described  in 
the  treatment  of  retention  from  enlarged  prostate.  Sepsis  is  the  most 
dangerous  and  frequent  sequel,  and  its  usual  cause  is  catheterization. 
Should  the  suction  catheter  or  the  evacuating-tube  not  succeed  in 
evacuating  the  bladder-contents,  or  should  there  be  frequent  recur- 
rence of  retention  from  clots,  requiring  repeated  catheterizations, 
median  perineal  cystotomy  is  indicated,  followed  by  the  insertion  of  a 
large  tube,  and  by  frequent  irrigations  of  the  bladder. 

Should  haematuria  persist  and  constitutional  symptoms  show  that 
loss  of  blood  is  producing  dangerous  anaemia,  surgical  intervention  is 
imperative.  This  should  take  the  form  of  an  exploratory  lumbar  in- 
cision. The  kidney  can  thus  be  thoroughly  exposed,  the  extent  of 
injury  determined,  and  the  bleeding  stopped  by  ligature  of  the  torn 
vessel,  ligation  and  excision  of  a  portion  of  the  kidney,  firm  pack- 
ing, or  nephrectomy.  This  last  operation  is  indicated  only  when  the 
kidney  exhibits  multiple  and  extensive  lacerations.  Lumbar  incision 
is  also  indicated  in  cases  exhibiting  no  blood  in  the  urine,  but  rapidly 
developing  a  lumbar  tumor  associated  with  symptoms  of  internal 
bleeding,  and  in  those  showing  the  constitutional  and  local  symptoms 
of  infection. 

Owing  to  the  depth  and  inaccessibility  of  the  wounded  vessels,  it 
may  be  impossible  to  tie  them,  or,  even  if  they  were  tied,  the  blood- 
supply  of  the  kidney  might  be  thereby  so  curtailed  that  necrosis  would 
be  certain  to  result.  Under  these  circumstances  nephrectomy  is  indi- 
cated.    Children  are  less  able  than  adults  to  resist  internal  hemor- 


544  GENITO-ITKINAEY    DISEASES   A:^rD   SYPHILIS. 

rhage,  but  are  apparently  more  likely  to  recover  from  nephrectomy. 
Therefore  nephrectomy  in  them  should  not  be  delayed  in  case  of  uncon- 
trollable internal  hemorrhage  from  ruptured  kidney.  In  one  of  Obalin- 
ski's  cases  the  indication  which  led  him  to  perform  nephrectomy  was 
the  formation  in  the  right  hypochondrium  on  the  ninth  day  after  the 
injury  of  a  tender,  circumscribed  tumor,  the  size  of  a  child's  head.  The 
kidney  was  immediately  exposed  by  a  lumbar  incision,  and  found  almost 
completely  severed  and  surrounded  by  a  large  quantity  of  healthy  urine 
and  small  blood-clots.  The  fragments  were  removed,  the  pedicle  was 
tied  off,  and  the  wound  was  packed  with  iodoform  gauze.  The  patient 
recovered.  Obalinski  favors  exposing  the  kidney  by  laparotomy  when 
after  injury  there  are  a  rapidly  formed  tumor,  profuse  hsematuria,  and 
other  indications  of  severe  hemorrhage.  This  incision  furnishes  an 
opportunity  of  washing  out  the  peritoneal  cavity  in  case  its  hning  mem- 
brane has  been  wounded  and  it  contains  blood  or  extravasated  urine. 

Of  four  hundred  and  eighty-six  cases  collected  by  Watson,  one 
hundred  and  twelve  died  ;  five  from  associated  injury  of  intraperitoneal 
organs,  twenty-five  from  suppuration,  ten  from  anuria,  nine  from  peri- 
tonitis. Of  two  hundred  and  seventy-three  cases  treated  expectantly, 
twenty-seven  per  cent,  died  ;  of  one  hundred  and  fifteen  cases  treated 
by  nephrectomy,  twenty-five  per  cent,  died ;  of  ninety-eight  cases 
treated  by  operation  other  than  nephrectomy,  seven  per  cent.  died. 
Hemorrhage  and  sepsis  caused  the  greatest  number  of  deaths. 

Wounds  of  the  Kidney. — Wounds  of  the  kidney,  much  rarer 
than  contusion  or  rupture,  are  conveniently  classed  in  accordance 
with  their  causes  as  gunshot,  punctured,  and  incised  wounds. 

Gunshot  Wounds. — A  bullet  which  wounds  the  kidney  is  very 
likely  to  injure  other  viscera.  Of  seventy-eight  cases  of  gunshot 
wound  of  the  kidney  reported  by  Otis,  other  viscera  were  wounded 
in  thirty-three.  Balls  usually  pass  through  the  kidney,  sometimes 
leaving  in  its  substance  portions  of  clothing ;  exceptionally  they  are 
buried  in  the  secreting  portion  of  the  organ :  thus,  Simon  found  a 
bullet  encysted  in  the  kidney  parenchyma. 

The  bullet  may  wound  simply  the  secreting  substance  of  the 
kidney,  may  pass  through  the  pelvis,  or  may  tear  the  great  vessels. 
The  modern  army  rifle,  either  at  close  or  at  long  range,  may  prac- 
tically pulpify  the  entire  organ.  When  the  wound  involves  only  the 
kidney-substance  there  is  moderate  bleeding  with  no  extravasation 
of  urine,  and,  provided  other  organs  are  spared,  healing  takes  place 
with  extraordinary  rapidity. 

When  the  pelvis  is  opened  there  will  be  urinary  extravasation. 
This,  however,  need  not  lead  to  infection.     The  bleeding  is  usually 


INJURIES   AND   DISEASES   OF    THE    KIDNEYS.  545 

more  profuse  than  when  only  the  secreting  substance  of  the  kidney 
is  involved,  and,  unless  the  ureter  is  torn  completely  across,  there 
will  be  hsematuria.  When  the  large  vessels  are  cut,  hemorrhage  is 
so  severe  as  to  threaten  life.  The  blood  may  be  poured  out  into  the 
perinephric  tissues,  into  the  peritoneal  cavity,  and  into  the  bladder 
through  the  ureter. 

Punctured  wounds,  such  as  those  made  with  a  needle  in  kidney 
exploration,  are  entirely  safe,  unless  infection  is  carried  with  the  vul- 
nerating  instrument.  When  made  with  a  comparatively  blunt  instru- 
ment, as  the  prong  of  a  hay-fork,  there  are  contusion  and  laceration 
in  addition  to  the  puncture,  and  the  consequences  are  the  same  as 
those  incident  to  gunshot  wound. 

Incised  wounds  are  rare,  since  the  position  of  the  kidney  protects 
it.  Incised  wounds  are  much  more  liable  to  be  entirely  extraperito- 
neal than  are  those  inflicted  by  fire-arms.  The  wound  of  entrance 
is  often  in  the  lumbar  region ;  stabs  and  cuts  inflicted  from  in  front 
rarely  extend  backward  as  far  as  the  kidney.  As  in  the  case  of 
gunshot  wounds,  these  injuries  may  involve  the  secreting  substance, 
may  open  the  pelvis,  may  divide  the  large  vessels,  or  may  sever  the 
ureter. 

A  few  cases  have  been  reported  in  which,  after  extensive  wound 
of  the  lumbar  region,  the  kidney  has  protruded. 

Symptoms. — The  chief  symptom  of  wound  of  the  kidney  is  haema- 
turia.  If  the  pelvis  has'been  opened  there  will  also  be  escape  of  urine 
through  the  wound.  Pain  may  be  severe,  assuming  the  type  of  kidney 
colic ;  oliguria  is  constant.  Exceptionally  there  is  complete  sup- 
pression of  urine. 

Diagnosis. — The  diagnosis  is  based  on — 1,  the  nature  of  the  vul- 
nerating  body,  its  direction,  and  the  depth  to  which  it  has  penetrated  ; 
2,  blood  in  the  urine ;  3,  escape  of  urine  from  the  wound ;  4,  exami- 
nation of  the  kidney  through  the  wound  or  through  a  lumbar  or  an 
abdominal  incision. 

When  the  entrance-wound  of  a  bullet  is  over  the  kidney,  and  the 
direction  of  its  track  is  towards  this  organ,  this  constitutes  a  reason- 
able ground  for  suspecting  injury  to  the  kidney,  since  the  course  of 
a  bullet  in  the  body  is  usually  straight ;  hsematuria  would  then  make 
the  diagnosis  reasonably  certain.  The  kidney  may,  however,  be  in- 
jured by  a  ball  which  enters  the  body  at  a  considerable  distance  from 
the  parietes  overlying  it.  Thus,  Otis  mentions  a  case  in  Avhich  the 
bullet  entered  just  below  the  clavicle.  Hgematuria  and  escape  of 
urine  through  the  wound  are  diagnostic  of  wound  of  the  pelvis  or  of 
the  ureter  rather  than  of  the  kidney. 

35 


546  GENITO-UEi:NrAKY   DISEASES    AND   SYPHILIS. 

Palpation  of  the  kidney  is  sometimes  possible  through  an  incised 
wound,  such  as  would  be  inflicted  by  a  stab  with  a  broad-bladed 
dirk ;  this  would  make  the  diagnosis  absolutely  certain. 

Prognosis. — Incised  wounds  of  the  kidney  heal  readily  ;  even 
though  the  pelvis  is  opened  and  there  is  escape  of  urine,  this  does 
not  materially  interfere  with  recovery,  provided  the  ureteral  lumen 
is  not  encroached  on.  These  injuries  are  dangerous  chiefly  from 
primary  hemorrhage,  which  is  likely  to  be  profuse,  and  from  the 
wounding  of  other  viscera.  Of  thirty-one  incised  wounds  collected 
by  Duplay  and  Rectus,  eight  died.  In  six  of  these  the  kidney-wound 
was  complicated  by  involvement  of  other  viscera. 

In  the  absence  of  profound  shock  and  severe  hemorrhage,  the 
prognosis  of  kidney-wound  is  favorable,  even  though  the  organ  is 
very  extensively  injured,  since  in  the  great  majority  of  cases  the 
wound  is  unilateral  and  occurs  in  persons  possessed  of  a  sound 
kidney  capable  of  performing  the  work  of  both.  The  prognosis  of 
wounds  from  in  front,  opening  the  peritoneum  overlying  the  kidney, 
is  much  more  serious  than  is  that  of  extraperitoneal  wounds. 

Gunshot  wounds  commonly  involve  other  viscera-.  Thus,  of 
thirty-eight  cases  collected  by  Duplay  and  Reclus,  sixteen  died ; 
eleven  of  these  deaths  were  attributable  to  multiplicity  of  the  lesions. 
The  complications  and  sequelae  of  wounds  of  the  kidney  are  those 
described  when  considering  contusions  ;  the  danger  of  infection  is 
greater  in  wounds  than  in  contusions,  since  it  may  reach  the  kidney 
either  from  the  ureter  or  from  the  parietal  opening. 

Treatment. — The  general  treatment  of  wound  of  the  kidney  is  that 
already  described  as  appropriate  to  contusion.  The  wound  itself 
should  be  scrupulously  disinfected,  and  should  be  drained,  even 
though  there  be  no  escape  of  urine,  since  the  vulnerating  body  is 
never  sterile. 

When  a  bullet  entering  the  body  from  in  front  has  passed  towards 
the  kidney,  and  there  follow  hsematuria  and  symptoms  of  internal 
hemorrhage,  cceliotomy  should  be  performed  at  once,  since  this  en- 
ables the  operator  not  only  to  deal  with  the  kidney,  but  to  recognize 
and  close  wounds  of  the  abdominal  viscera. 

When  the  wound  is  in  the  lumbar  region  and  there  is  doubt  as  to 
whether  or  not  the  peritoneal  cavity  has  been  entered,  the  lumbar 
incision  is  preferable.  The  indication  for  immediate  operation,  as  far 
as  the  kidney  is  concerned,  is  hemorrhage.  The  kidney  having  been 
exposed,  either  by  an  incision  through  the  linea  alba,  along  the  outer 
border  of  the  rectus  muscle,  or  in  the  lumbar  region,  according  to  the 
position- of  the  wound,  the  bleeding  point  is  sought  for  and  secured. 


INJUKIES   AND   DISEASES    OF   THE    KIDNEYS.  547 

by  ligature,  if  this  is  possible,  or  by  packing  in  case  the  ligature  cannot 
be  applied  and  there  seems  a  fair  prospect  of  saving  the  kidney,  or 
by  nephrectomy. 

If  the  wound  involves  only  the  secreting  portion  of  the  kidney,  it 
should  be  cleaned,  and  packed.  If  the  renal  artery  or  vein  is  torn, 
or  if  the  kidney  is  so  extensively  disorganized  that  repair  is  abso- 
lutely impossible,  nephrectomy  is  indicated.  If  the  pelvis  is  opened, 
it  should  be  closed  by  suture,  if  possible  ;  if  not  possible,  provision 
should  be  made  for  lumbar  drainage.  If  the  ureter  is  torn  across 
its  upper  portion,  lumbar  drainage  is  usually  indicated,  since  from 
loss  of  blood  the  patient  is  not  prepared  to  stand  a  prolonged  plastic 
operation.  Should  recovery  take  place,  implantation  of  the  ureter 
into  the  pelvis  may  be  effected  subsequently.  Blood  or  extravasated 
urine  found  in  the  peritoneal  cavity  should  of  course  be  removed  by 
sponging,  the  kidney  being  then  shut  off  from  this  cavity  by  suture  of 
the  peritoneum.  Extensive  accumulation  of  blood  in  the  perinephric 
and  post-peritoneal  tissues  should  be  removed,  since  huge  abscesses 
will  otherwise  develop  if  infection  occurs. 

Incised  wounds  of  the  kidney  are  treated  by  gauze  drainage  if 
hemorrhage  is  moderate.  If  it  is  persistent  and  severe,  the  kidney 
should  be  exposed  by  lumbar  incision,  the  bleeding  vessels,  if  large, 
secured  by  ligature,  or  the  hemorrhage  stopped  by  packing,  and  the 
kidney-wound  closed  by  catgut  suture.  Stitches  are  serviceable  in 
these  cases  as  a  means  of  hsemostasis  ;  they  also  materially  hasten  the 
process  of  cicatrization.  When  a  large  portion  of  the  kidney  is  almost 
entirely  cut  away,  this  should  be  removed.  If  the  renal  artery  is  cut, 
nephrectomy  is  indicated. 

Nephrectomy. — When  the  wound  is  extraperitoneal  the  lumbar 
route  may  be  chosen,  though  many  surgeons  of  experience  have 
abandoned  it  in  favor  of  the  abdominal  operation. 

The  incision  should  be  four  inches  long,  beginning  about  two  and 
a  half  inches  from  the  spines  of  the  vertebrae,  and  running  parallel 
to  the  twelfth  rib,  and  a  full  half  inch  below  it,  in  order  to  avoid 
wounding  the  pleura,  which  sometimes  extends  down  to  the  twelfth 
rib.  This  wound  may  be  enlarged,  if  necessary,  by  another  incision 
carried  downward  from  its  inner  third  to  the  crest  of  the  ihum. 
When  the  kidney  has  been  exposed,  as  in  nephrorrhaphy,  and  freed 
from  any  adhesion  to  its  fatty  capsule,  and  blood-clots  have  been 
removed,  its  pedicle  should  be  double  clamped  with  forceps,  and  it 
should  be  removed  by  cutting  between  these  instruments,  after  which 
the  vessels  and  the  ureter  are  separately  ligated.  The  kidney  can 
then  be  drawn  out  of  the  wound  and  the  vessels  and  the  ureter  tied 


548  GENITO-UEINAEY  DISEASES   AND   SYPHILIS. 

off  again  near  the  pelvis  of  the  kidney  to  prevent  escape  of  urine  into 
the  wound,  and  the  pedicle  cut  between  the  two  ligatures.  The 
wound  should  be  irrigated  with  sterilized  water  or  sublimate  solution 
and  packed  with  sterile  gauze,  or  it  maybe  partially  closed  and  drained 
with  a  rubber  tube,  which  should  be  removed  in  three  or  four  days. 

Nephrectomy  through  an  incision  in  the  linea  semilunaris,  known 
as  Langenbuch's  operation,  is  indicated  when  the  wound  has  probably 
involved  other  organs  and  has  opened  the  peritoneal  cavity.  This 
incision  to  allow  of  free  manipulation  should  be  at  least  four  inches 
long.  When  bleeding  points  have  been  secured  and  the  abdominal 
cavity  has  been  opened,  as  in  all  other  laparotomies,  the  opposite 
kidney  is  palpated,  not  only  to  make  sure  of  its  existence,  but, 
furthermore,  to  ascertain,  as  far  as  possible,  its  condition  of  health 
and  whether  or  not  it  can  endure  the  strain  of  double  duty.  If  it  be 
absent  or  diseased,  the  operation  must  be  abandoned.  If  this  exam- 
ination of  the  uninjured  kidney  shows  that  it  is  probably  healthy,  the 
intestines  are  pushed  aside  from  the  affected  kidney,  the  outer  layer 
of  the  mesocolon  is  exposed,  and  a  vertical  slit  is  cut  in  it  over  the 
kidney,  the  general  cavity  being  sufficiently  protected  by  careful  gauze 
packing. 

If  the  peritoneum  has  been  wounded,  blood  and  extravasated 
urine  are  sponged  out  and  intraperitoneal  injuries  are  treated  before 
dealing  with  the  kidney,  unless  there  is  bleeding ;  in  that  case  no  time 
is  lost  in  fully  exposing  the  organ.  The  kidney  is  enucleated  from  its 
fatty  capsule  as  in  the  lumbar  operation,  and  the  vessels  and  ureter  are 
tied  off  and  divided.  It  is  advisable  in  this  operation  to  provide  drainage 
through  a  lumbar  wound  for  three  or  four  days.  Unless  there  are  lesions 
of  the  abdominal  viscera,  or  unless  from  the  nature  of  the  wound  it  is 
probable  that  infection  will  follow,  the  peritoneum  overlying  the  kid- 
ney should  be  completely  closed  by  suture,  and  the  abdomen  closed 
without  drainage.  When  abdominal  nephrectomy  is  performed  after 
infection  has  developed,  the  peritoneal  cavity  must  be  freely  drained. 

In  abdominal  nephrectomy  performed  through  an  incision  in  the 
linea  alba  the  operation  is  exactly  the  same  as  an  ordinary  abdominal 
section  up  to  the  time  when  the  inner  layer  of  the  mesocolon  is 
incised  in  order  to  reach  the  postperitoneal  kidney-space.  Thereafter 
the  procedure  is  the  same  as  in  Langenbuch's  operation.  Profuse 
hemorrhage  from  cutting  one  of  the  large  veins  running  along  the 
inner  layer  of  the  mesocolon  frequently  happens  ;  this  may  be  pre- 
vented by  cutting  in  the  line  of  the  veins,  or  by  tying  beforehand 
those  vessels  which  inevitably  must  be  cut.  Drainage  should  be 
secured  through  a  counter-opening  in  the  lumbar  region. 


INJUKIES   AND   DISEASES    OF   THE    KIDNEYS.  549 

The  main  advantage  of  the  abdominal  route  is  the  opportunity  it 
affords  of  examining  into  the  condition  of  the  uninjured  kidney  and 
of  detecting  and  repairing  associated  injuries  of  the  intraperitoneal 
viscera. 

Foshay  studied  the  changes  in  the  urine  after  nephrectomy  in 
two  cases,  and  in  both  found  evidence  of  temporary  hyperasmia  of 
the  remaining  kidney. 

Meyer,  after  reporting  a  case  of  anuria  following  nephrectomy, 
in  which  nephrotomy  was  performed,  remarks,  "  There  evidently 
occurs  an  excessive  hyperaemia  in  the  remaining  kidney  immediately 
after  nephrectomy.  Its  presence  is  demonstrated  by  the  sudden 
change  in  the  transparency  of  the  urine  if  that  remaining  kidney  had 
already  been  slightly  affected.  It  has  been  observed  by  many  who 
have  done  several  nephrectomies  that  in  a  number  of  cases  imme- 
diately after  the  one  unhealthy  kidney  has  been  removed  the  urine 
which  descends  from  its  probably  only  slightly  affected  fellow,  and 
which  had  formerly  been  found  comparatively  clear,  with  the  help  of 
cystoscopy,  or  after  nephrotomy  on  the  other  side  had  been  done, 
suddenly  becomes  very  turbid,  and  presents  an  unusually  heavy 
deposit  after  short  standing.  As  I  have  seen,  it  can  take  weeks  or 
months  before  this  turbidity  lessens  or  disappears.  In  the  majority 
of  cases  it  does  so,  however,  but  slowly  and  gradually." 

Schede  also  mentions  the  arterial  pressure  necessarily  present 
and  suddenly  increased  in  the  remaining  kidney  after  nephrectomy 
on  the  opposite  side.  He  is  inclined  to  regard  it  as  the  probable 
cause  of  the  acute  epithelial  necrosis  in  the  tubuli  contorti  of  the 
kidney,  which  has  been  found  on  microscopical  examination  of  the 
remaining  kidney  in  a  few  instances  after  nephrectomy,  and  to  which 
the  immediate  fatal  result  of  the  operation  evidently  was  due. 


CHAPTER   XV. 

KIDXEY    CALCULI. 

Uric  acid  calculi  are  found  more  frequently  than  any  other  form 
of  kidney  stone.  Next  come  oxalate  calculi.  These  are  both  de- 
posited from  acid  urine,  and  are  partly  dependent  for  their  formation 
on  systemic  conditions. 

Phosphatic  calculi  and  those  made  up  of  calcium  carbonate  are 
less  frequent.  They  are  deposited  from  alkahne  urine,  and  infection 
is  a  strong  predisposing  factor  in  their  formation.  Litten  has  shown 
experimentally  that  temporary  hgature  of  the  renal  artery  is  followed 
by  calculous  infiltration  of  the  degenerated  epithelium,  which  subse- 
quently may  be  transformed  into  true  calculi. 

Cystin,  xanthin,  ammonium  urate,  or  other  urates  are  rare  as  the 
principal  ingredients  of  kidney  stone.  It  is  possible  that  calcuh  may 
originate  in  the  renal  pelvis  about  a  minute  clot.  Exceptionally  con- 
cretions are  found  made  up  almost  entirely  of  inspissated  blood. 
Foreign  bodies  servmg  as  nuclei  are  extremely  rare.  Franks  has, 
however,  reported  a  case  in  which  an  ordinary  sewing-needle  formed 
the  nucleus  of  stone  which  caused  an  extensive  perinephric  abscess. 
The  needle  had  been  swallowed  in  childhood,  and  had  finally  pene- 
trated the  pelvis  of  the  kidney  and  there  become  encrusted  with 
urinary  salts.  Rosenstein  found  a  calculous  deposit  about  a  hair, 
evidently  from  a  dermoid  cyst  of  the  kidney. 

The  number  of  calculi  may  vary  from  one  to  a  thousand.  In 
shape  they  are  seldom  round  or  regular,  owing  both  to  the  shape  of 
the  cavity  wherein  they  are  contained  and  to  their  restricted  attrition 
from  motio-n.  One  large  calculus  and  numerous  small  ones  may  be 
found  filling  up  the  renal  pelvis,  in  which  case  the  larger  calculus 
acting  as  a  ball-valve  may  partially  close  the  entrance  to  the  ureter 
and  only  occasionally  allow  smaller  calculi  to  pass  down.  Such  may 
be  the  case  when  frequent  attacks  of  renal  colic  are  followed  by  the 
passage  of  smaU  calculi  per  urethram.  but  the  general  symptoms  do 
not  ameliorate. 

Kidney  calculi  are  usually  found  in  the  pelvis  or  its  branchings. 
Exceptionahy  they  are  placed  in  the  substance  of  the  kidney,  as  is  the 
case  when  the  urate  infarcts  of  the  newly-born  form  true  stones.     In 

550 


Fig.  175. 


"■IJA^ 


Various  forms  of  kidney-stone,  illustrating  the  irregularities  in  shape.     (Torres.) 


Fig.  176. 


i    Vi£ 


(J 


Lovis^chraidtfec' 


Various  kinds  of  uniiarv  calculi. 


KIDNEY   CALCULI. 


551 


the  absence  of  infection  calculus  is  generally  adherent,  taking  the  shape 
of  the  portion  of  the  pelvis  in  which  it  is  placed,  often  bifurcating  and 
branching  like  a  piece  of  coral,  and  representing  a  rough  mould  of  the 
pelvis  and  its  subdivisions.  (Fig.  175.)  When  infection  has  taken 
place,  calculi  may  be  found  in  any  portion  of  the  pelvis,  perhaps  most 
frequently   in    its    upper    and 

lower  extremities.     Both  kid-  Fig-  177. 

neys  are  affected  in  about  fif- 
teen per  cent,  of  cases. 

A  calculus  of  moderate  size 
may  remain  indefinitely  in  the 
kidney  without  producing  the 
slightest  pathological  change  in 
the  secreting  structure.  If  the 
calculus  is  so  placed  that  it  sud- 
denly and  completely  blocks 
the  ureteral  orifice,  the  kidney 
will  atrophy.  As  a  usual  se- 
quel there  is  gradual  dilatation 
of  the  pelvis  and  its  branches, 
due  to  partial  obstruction.  This 
may  result  in  either  hydrone- 
phrosis or  atrophy.  When  in- 
fection has  taken  place, — and 
this  occurs,  as  a  rule, — there 
result  pyelonephritis,  pyone- 
phrosis, and  often  secondary 
purulent  deposits.  As  a  com- 
plication of  the  kidney  infection 
an  indurative  or  suppurative 
perinephritis  may  develop. 

Uric  acid  stones  form  two- 
thirds    of    all    renal     calculi. 

(Prout.)  They  vary  in  size  from  that  of  a  grain  of  sand  to  that  of  a 
goose-egg.  The  surface  is  usually  smooth,  sometimes  granular ;  the 
color  is  dark  yellow  or  red.  The  whole  concrement  may  be  made  up 
of  uric  acid.  Frequently  it  is  composed  of  a  nucleus  of  uric  acid  with 
oxalate  layers  placed  about  this,  and  finally  a  superficial  coating  of  the 
earthy  phosphates. 

Oxalate  stones,  formed  about  a  nucleus  of  epithelium,  have  been 
found  in  the  secreting  substance  of  the  kidney  ;  they  are  apt  to  be 
of  a  dark  brown  or  black  color.     When  found  in  the  pelvis  of  the 


Multiple  bilateral  renal  cysts  and  ralpuli.     (Specimen 
in  Philadelphia  Hospital  Museum.) 


552  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

kidney  they  are  generally  round  if  single,  faceted  if  multiple,  with  a 
rough  surface.  They  are  harder  than  the  uric  acid  calculi.  They 
ordinarily  show  a  nucleus  of  uric  acid. 

Cystin  calculi  are  commonly  made  up  of  this  ingredient  alone. 
They  are  light  yellow  in  color,  and  exhibit  a  smooth  or  a  rough 
surface  ;  they  turn  greenish  or  bluish  on  exposure  to  air. 

Xanthin  calculi  are  extremely  rare. 

Phosphate  calculi  do  not  often  form  the  entire  bulk  of  a  concre- 
ment.  They  are  usually  deposited  as  an  outer  shell  upon  the  uric  or 
oxalate  stones.     They  are  light  gray  in  color  and  comparatively  soft. 

Fig.  178. 


Eenal  calculus.    (Actual  size. )    (American  Text-Book  of  Surgery.) 

Calcium  carbonate  stones  are  exceptional  in  man.  Marcet  has 
found  in  diverticula  of  the  pelvis  yellowish  or  grayish  concrements 
of  dense  elastic  structure  made  up  entirely  of  fibrin. 

In  dealing  with  renal  calculi  the  degree  of  hardness  is  of  no 
moment.  Owing  to  their  position,  it  is  impossible  to  crush  them  or 
wash  them  away  from  the  pelvis  of  the  kidney ;  they  must  either  be 
removed  entire,  or,  if  soft  and  friable,  be  broken  up  and  removed 
with  a  scoop. 

Etiology. — The  formation  of  kidney  calculi  is  due  to  the  precipita- 
tion in  the  kidney  tubules  or  pelvis  of  the  solid  constituents  of  the 
urine.  This  precipitation  always  takes  place  on  an  organic  base. 
This  may  be  mucus,  epithelial  cells,  blood-clot,  or  colloid  material; 


KIDNEY   CALCULI.  553 

it  has  already  been  mentioned  that  a  coagulation  necrosis  of  cells 
caused  by  interference  with  the  circulation  favors  deposition  of  lime 
salts.  All  concrements,  whether  they  be  the  size  of  a  grain  of  sand  or 
of  a  goose-egg,  have  a  distinct  albuminoid  framework  upon  which  the 
constituents  of  the  urine  are  deposited.  The  difference  between  sand 
and  sediment  lies  in  the  fact  that  in  the  former  the  crystals  are  con- 
glomerated about  this  organic  framework. 

Diathesis  possesses  a  distinct  influence  upon  stone-formation, 
which  is  commonly  associated  with  the  uric  acid,  the  oxalate,  or  the 
phosphatic  diathesis.  Ebstein  holds  that  the  excess  of  urates,  oxa- 
lates, or  phosphates  in  the  urine  does  not  form  stone  by  direct  deposi- 
tion in  the  excretory  canals  or  pelvis  of  the  kidney,  but  that  these 
ingredients  favor  a  coagulation  necrosis  of  cells,  which  furnishes  the 
organic  framework  essential  for  calculus  formation ;  the  same  effect 
is  produced  by  local  sepsis. 

Heredity  exerts  a  direct  influence  on  the  development  of  kidney 
calculi.  Leroy  d'fitiolles  records  the  fact  that  of  a  family  of  eight 
brothers  who  lived  in  various  parts  of  Europe  under  different  condi- 
tions of  hygiene  all  had  calculi.  Toel  observed  calcuh  and  gravel 
in  a  mother  and  two  daughters. 

Uric  acid  kidney  stones  have  been  found  in  the  foetus.  In  general 
renal  calculi  are  most  frequently  observed  in  children  and  after  the 
fortieth  year.  The  uric  infarct  of  the  newly-born,  appearing  as  a 
deposition  of  red  and  brown  crystals,  particularly  of  ammonium 
urate,  in  the  epithelium  of  the  pyramidal  tubules,  may  account  for 
the  frequency  of  vesical  calculi  in  children  ;  kidney  colic  is,  however, 
rare  at  an  early  age. 

Renal  calcuM  are  commoner  in  men  than  in  women,  the  ratio 
being  given  as  three  to  one.  Duplay  and  Reclus,  however,  hold  that 
the  two  sexes  are  equally  affected. 

Hygienic  surroundings,  chmate,  and  diet  seem  to  have  a  definite 
relation  to  the  formation  of  kidney  stone,  but  one  which  has  not  been 
clearly  formulated.  Moist  climates  and  sudden  changes  of  temperature 
apparently  predispose  to  calculus-formation. 

Men  who  lead  sedentary  lives  and  indulge  in  high  living  are  more 
liable  than  others  to  urinary  concretions.  The  frequency  with  which 
renal  calculi  are  found  among  the  children  of  the  poorer  classes  has 
been  attributed  to  unfavorable  hygienic  surroundings  and  course  diet. 
It  is  believed  to  be  due  to  the  absence  of  milk  from  the  diet  of  such 
children.  This  is  an  original  observation  of  Mr.  Cadge,  and  is  well 
illustrated  by  the  story  which  he  has  published  in  corroboration:  "A 
few  years  ago,  after  removing  a  stone  from  a  child  of  well-to-do 


554  GEXITO-UPa]SrAPvY   DISEASES   AND   SYPHILIS. 

parents,  I  was  remarking  to  one  of  my  assistants  that  this  was  the  first 
instance  in  my  practice,  and  that  I  attributed  the  general  absence  of 
stone  in  such  persons  to  tlie  free  use  of  milk ;  the  mother  volun- 
teered the  statement  that  in  a  large  family  this  was  her  only  child 
who  never  could  take  milk,  and  who  therefore  never  had  had  any." 

In  opposition  to  this  belief  it  is  interesting  to  note  that  Cantani 
believes  that  the  ingestion  of  starches  and  of  milk  plays  a  major  role 
in  the  production  of  kidney  calculi. 

Symptoms. — The  chief  symptoms  of  renal  calculus  are  pain,  hsema- 
turia,  frequent  urination,  fragments  of  calculus  appearing  with  the 
urine,  pyuria,  oliguria  or  suppression,  and  symptoms  of  gastro-intes- 
tinal  disturbance.  A  stone  may,  however,  be  present  in  the  kidney 
for  many  years,  or  through  an  entire  lifetime,  without  producing 
symptoms. 

The  symptoms  caused  by  kidney  stone  are  due  to  obstruction 
rather  than  to  the  presence  of  a  foreign  body :  hence  the  position  of 
the  stone  is  of  more  importance  than  its  shape  or  size.  Guyon  com- 
ments on  the  tolerance  of  the  kidneys  and  ureters  to  foreign  bodies  as 
contrasted  to  their  sensitiveness  to  distention. 

The  pain  of  renal  calculus  is  commonly  referred  to  the  lumbar 
region  of  the  affected  side.  It  is  constant  and  aching  in  character,  and 
is  increased  by  motion,  by  jarring,  and  by  pressure  over  the  kidney. 
It  begins  as  a  feeling  of  weight  or  tension  rather  than  as  an  actual 
pain.  It  is  subject  to  sudden  exacerbations,  often  occurring  at  night 
when  the  patient  is  completely  at  rest.  It  may  be  referred  to  the 
healthy  kidney.  Neuman  reports  two  such  cases,  which  were  cor- 
roborated by  the  skiagraph  and  by  subsequent  operation.  In  its 
exacerbations  it  usually  radiates  along  the  course  of  the  ureter  and 
into  the  testicle,  and  may  cause  contraction  of  the  cremaster  muscle, 
with  retraction  of  the  gland.  It  may  be  referred  to  the  thigh  or  the 
calf  of  the  leg. 

The  reflexes  of  renal  calculus  occasionally  take  the  form  of  intes- 
tinal disturbances,  characterized  by  vomiting  and  violent  intestinal 
colic.  Rectal  and  vesical  tenesmus  are  not  rare.  Urgent  and  pain- 
ful urination  is  often  so  marked  that  attention  is  diverted  from  the 
kidney  to  the  bladder. 

Renal  tenderness  elicited  on  deep  palpation  is  a  valuable  symp- 
tom. Lloyd  lays  considerable  stress  upon  the  characteristic  stab- 
bing pain  which  is  caused  by  deep  percussion  over  the  loin  of  the 
affected  side. 

Attacks  of  kidney  colic  when  they  are  recurrent  and  are  induced 
by  bodily  activity  are  particularly  characteristic  of  renal  calculi.     (See 


KIDNEY   CALCULI.  555 

page  516.)  Perfectly  typical  paroxysms  may,  however,  occur  without 
the  presence  of  stone.  This  is  proved  not  only  by  the  large  number 
of  cases  reported  in  which,  the  diagnosis  having  been  based  mainly 
on  this  symptom,  the  kidney  was  opened  and  no  stone  found,  but 
also  by  the  cases  in  which,  the  kidney  having  been  exposed  to  sight 
and  touch,  rhythmical  contractions  of  the  ureter  were  observed.  This 
offers  another  explanation, — that  of  ureteral  colic,  which  may  be  ex- 
cited by  divers  conditions,  and  would  naturally  have  subjective 
symptoms  very  like  those  characterizing  kidney  colic. 

Hsematuria  is  usually  slight  and  transitory,  and,  except  after  the 
attacks  of  kidney  colic,  can  often  be  detected  only  by  microscopic  ex- 
amination. Clots  are  rare.  The  amount  of  blood  in  the  urine  is 
increased  by  jolting,  walking,  muscular  efforts,  or  renal  palpation ; 
there  is  sometimes  enough  to  give  the  urine  a  smoky  appearance. 
Sometimes  bright-red  blood  is  passed,  but  this  is  much  more  char- 
acteristic of  tumor  than  of  calcuh ;  this  is  true  also  of  clots.  Rest  in 
bed  exerts  a  prompt  and  markedly  beneficial  effect  upon  the  hema- 
turia. There  are  often  found  in  the  urine  blood-cylinders, — i.e., 
casts  of  the  uriniferous  tubules  made  up  of  blood-cells ;  these  are 
absolutely  characteristic  of  hemorrhage  of  renal  origin. 

Frequent  urination,  as  a  pure  reflex  from  renal  and  ureteral  irri- 
tation, is  often  a  troublesome  symptom  during  the  daytime,  but  is 
reheved  wheji  the  patient  is  at  rest.  Jacobson  observes  that  noc- 
turnal and  diurnal  frequency  of  urination,  when  associated  with  other 
symptoms  suggesting  renal  calculus,  indicates  renal  tuberculosis  with 
extension  of  the  process  to  the  bladder-walls,  rather  than  renal  cal- 
culus. The  frequent  urination  of  kidney  calculus  is  usually  unat- 
tended by  pain.  When,  together  with  frequency  and  urgency,  there 
are  marked  tenesmus  and  suffering  during  and  after  the  act  of  mic- 
turition, these  symptoms  are  attributable  to  concomitant  inflamma- 
tion. 

The  passage  of  gravel  or  of  fragments  of  calculi  is  a  symptom  com- 
monly wanting ;  when  present  it  is  of  great  value  as  indicating  kid- 
ney stone,  even  though  its  passage  along  the  ureter  does  not  cause 
symptoms  of  kidney  colic. 

Diminution  or  total  suppression  of  the  urine  lasting  for  a  few 
hours  is  a  fairly  frequent  symptom  of  kidney  colic.  When  it  lasts  a 
much  longer  time  it  should  be  attributed  to  the  simultaneous  obstruc- 
tion of  both  ureters,  or  to  obstruction  of  the  ureter  of  the  only  func- 
tioning kidney. 

Exceptionally  this  obstruction  may  begin  insidiously,  attracting  no 
attention  until  the  symptoms  of  uraemia  set  in.      For  six  or  eight 


556  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

days  there  may  be  no  characteristic  symptoms  other  than  failure  to 
pass  water.  After  this  period  constitutional  symptoms  develop,  in 
the  form  of  stupor,  tympany,  diarrhoea,  subnormal  temperature,  dry 
black  tongue,  often  hiccough  and  uraemic  odor  of  the  breath.  The 
obstruction  is  usually  placed  in  or  near  the  pelvis :  hence  lumbar 
incision  and  nephrotomy  are  indicated. 

Gastro-intestinal  disturbances  are  either  reflex  or  due  to  imper- 
fect elimination  on  the  part  of  the  crippled  kidneys.  Tympany,, 
vomiting,  and  exquisite  tenderness  at  times  comphcate  and  greatly 
obscure  attacks  of  renal  cohc.  Chronic  epigastric  tenderness,  feeble 
digestion,  and  constant  pain  may  direct  the  attention  entirely  away 
from  the  kidney. 

Pyuria  is  a  sign  of  pyelonephritis ;  it  is  classed  as  a  symptom  of 
kidney  calculus  simply  because  it  is  so  frequent  a  complication ; 
infection  markedly  aggravates  the  pain,  the  reflexes,  and  the  other 
symptoms  already  described ;  it  also  causes  fever  and  favors  the  de- 
velopment of  pyonephrosis. 

Diagnosis. — The  diagnosis  of  kidney  stone  is  based  on  lumbar 
pain  with  intercurrent  attacks  of  nephritic  colic,  slight  albuminuria 
with  hyaline  casts,  haematuria,  the  passage  of  gravel  or  of  fragments 
of  calculi,  renal  tenderness,  and  the  use  of  the  X-ray.  These  symp- 
toms are  rarely  all  present.  Pain  and  hsematuria  are  the  two  most 
constant,  and,  with  the  exception  of  the  passage  of  calculus  fragments, 
the  most  characteristic.  Tenderness  may  be  elicited  either  by  palpa- 
tion or  by  directing  the  patient,  while  in  a  standing  position,  to 
strongly  flex  the  thigh  of  the  affected  side  and  then  suddenly  extend 
it,  bringing  the  heel  forcibly  to  the  floor.  If  a  calculus  be  present,  this 
movement,  called  the  stamping  test,  may  cause  sudden  acute  renal 
pain.  (Lucas.)  Movable  kidney  often  causes  constant  pain  and  acute 
exacerbations  precisely  like  those  which  arise  from  stone.  Sometimes 
blood  is  mixed  with  the  urine,  but  only  after  an  acute  attack  of  pain  \ 
the  movable  kidney  can  sometimes  be  felt  in  its  abnormal  position. 

Nephralgia  may  simulate  renal  calculus  in  all  respects  except  in 
the  presence  of  blood  or  pus  in  the  urine,  though  Sabatier  states  that 
this  affection  also  causes  haematuria.  Large  quantities  of  limpid  urine 
of  low  specific  gravity  are  passed,  and  the  suffering  is  aggravated  at 
the  catamenia. 

Tuberculosis  of  the  kidney  in  its  early  stages  may  simulate  renal 
calculus  so  closely  that  an  exploratory  incision  will  be  required  before 
a  differential  diagnosis  can  be  established.  There  is  haematuria  which 
is  apparently  causeless,  and  the  characteristic  reflexes  develop.  Renal 
tuberculosis  is  often  associated  with  hereditary  dyscrasia  and  tubercu- 


Fig,  179. 


Roentgen  ray  shadowgraph  showing  calcuhis  in  ilie  pelvis  of  the  left  kidney. 

the  colon  are  also  shown. 


The  renal  artery  and 


Fig.  180. 


Calculus  impacted  in  first  portion  of  ureter.     (Skiagraph  made  by  Dr.  H.  K.  Pancoast.) 


KIDNEY   CALCULI.  557 

lar  infiltration  of  the  epididymis,  prostate,  and  vesical  walls.  More- 
over, repeated  and  patient  search  will  sometimes  show  the  tubercle 
bacilli.  Tubercular  kidney  seems  more  subject  to  mixed  infection 
than  is  the  case  in  calculous  kidney  :  hence  there  is  often  a  great  deal 
of  pus  in  the  urine ;  this  may  be  thick  and  contain  caseous  particles, 
which  rapidly  settle  to  the  bottom  of  the  vessel  in  which  the  urine 
has  been  passed. 

Malignant  growths  are  characterized  by  hsematuria  much  more 
pronounced  than  that  due  to  calculus,  clots  often  appearing  in  the 
urine  in  the  shape  of  ureteral  moulds  ;  the  growth  rapidly  and  steadily 
increases  in  size.  Fragments  of  the  growth  are  sometimes  passed  in 
the  urine,  and  these  in  obscure  cases  may  be  the  only  reliable  means 
of  forming  a  diagnosis.  Exploratory  operation  is  justifiable  under 
these  circumstances. 

Oxaluria  and  strongly  acid  urine  cause  dull  ache,  paroxysmal  pain, 
and  haematuria.  The  pain  is,  however,  not  materially  increased  on 
exertion,  the  tenderness  is  not  distinctly  marked  on  deep  palpation, 
and  treatment  is  followed  by  prompt  relief. 

Pyelitis  cannot  be  distinguished  from  renal  calculus  with  infection 
except  by  the  history  of  the  case.  Pain  is  not  likely  to  be  so  dis- 
tinctly paroxysmal. 

Spinal  caries  involving  the  lower  dorsal  or  the  lumbar  vertebree 
may  in  its  symptomatology  closely  simulate  kidney  stone.  Thus, 
Wright  reports  a  case  characterized  by  increased  frequency  of  urina- 
tion, intermittent  attacks  of  pain  causing  nausea  and  vomiting,  tes- 
ticular pain  and  local  tenderness,  and  oxaluria.  An  abscess  had 
formed  in  the  neighborhood  of  carious  vertebrae  and  by  pressure  on 
the  kidney  had  caused  symptoms  of  calculus. 

The  distinction  between  kidney  stone  and  gall  stone  may  be  quite 
impossible  during  an  acute  attack  of  colic.  The  anterior  position  of 
the  pain  and  tenderness  with  backward  and  upward  radiations,  the 
absence  of  blood  or  pus  from  the  urine,  the  abundant  secretion  during 
the  attack,  and  a  preceding  history  of  persistent  gastro-intestinal  dis- 
turbances and  attacks  of  jaundice  would  all  suggest  hepatic  colic. 
Appendicitis  has  frequently  been  confounded  with  renal  calculus  com- 
plicated by  hydro-  or  pyonephrosis,  but  is  characterized  by  the  seat  of 
the  tenderness  and  tumor,  the  persistent  character  of  the  pain  and 
gastro-intestinal  disturbances,  the  unmistakable  rigidity  of  the  right 
rectus  muscle,  the  absence  of  blood  and  pus  from  the  urine,  and 
the  pronounced  pyrexia  and  leucocytosis.  Marked  flexion  of  the 
thigh  is  more  common  in  renal  colic  than  in  appendicitis. 

Locomotor  ataxia  and  hysteria  may  produce  symptoms   closely 


558  GENITO-URIiSTxiEY   DISEASES   AND   SYPHILIS. 

simulating  those  of  renal  calculus.     Examination  of  the  urine  should 
exclude  kidney  stone. 

It  will  thus  be  seen  that  in  many  cases  a  positive  diagnosis  of 
renal  calculus  cannot  be  made.  This  is  well  shown  by  the  history 
of  renal  surgery.  Even  the  X-ray  may  fail  to  show  a  stone,  and  this 
is  particularly  the  case  with  uric  acid  calculi. 

Morris  has  reported  twenty-eight  cases  in  which  he  was  unable  to 
confirm  the  presence  of  a  stone,  although  the  symptoms  strongly 
suggested  that  this  was  present.  Tubercular  nephritis,  pyelonephritis, 
perinephritis,  movable  kidney,  prostatic  abscess,  calculus  of  the  pros- 
tate, encysted  stone  in  the  lower  end  of  the  ureter,  disease  of  the 
neighboring  organs,  and  disease  of  the  vertebrae,  with  consecutive 
perinephric  pus-formation  were  some  of  the  conditions  encountered. 
In  some  cases  neither  stone  nor  any  other  cause  for  symptoms  was 
found. 

In  thin  persons,  and  when  there  are  many  concrements,  on  palpa- 
tion both  tumor  and  crepitus  can  be  detected,  the  latter  particularly  by 
combining  palpation  with  auscultation.     This  is,  however,  exceptional. 

The  most  characteristic  diagnostic  symptoms,  placed  in  their  order 
of  importance,  are  an  unmistakable  skiagraph,  passage  of  gravel  or 
of  fragments  of  stone,  attacks  of  typical  renal  colic,  hsematuria,  and 
ultimately  pyelitis.  It  is  clear  that  prolonged  study  of  the  urine  is 
necessary  before  forming  a  diagnosis,  the  results  of  this  study  often 
sufficing  to  exclude  affections  which  simulate  renal  calculi. 

Diagnosis  of  Urio  Acid  Calculi.— The  concretions  are  finely  pow- 
dered, and  a  portion  in  a  test-tube  is  treated  with  dilute  cold  hydro- 
chloric acid ;  if  effervescence  occurs,  carbonates  are  present,  and  if 
the  material  dissolves,  it  is  not  uric  acid.  If  only  a  very  little  or  no 
solution  occurs,  the  residue  is  treated  with  a  large  quantity  of  ivarm 
dilute  hydrochloric  acid.  The  sulphates,  oxalates,  phosphates,  cystin, 
and  xanthin  wiU  now  go  into  solution,  and  any  residue  is  presumably 
uric  acid.  This  may  then  be  filtered  off,  dried,  and  heated  on  plati- 
num foil ;  a  distinct  odor  of  bitter  almonds  (HCN)  speaks  for  uric 
acid.  Finally,  the  murexid  test  may  be  applied  to  make  the  diagnosis 
certain.  A  small  cjuantity  of  the  material  is  dissolved  in  nitric  acid, 
and  a  few  drops  of  the  solution  evaporated  to  dryness  in  a  porcelain 
dish  ;  the  residue  should  be  red.  A  drop  of  ammonium  hydroxide 
will  produce  a  purple  color,  a  drop  of  potassium  or  sodium  hydrate 
a  reddish-blue.     (Crofton.) 

It  is  of  extreme  importance  to  determine  whether  one  or  both 
kidneys  are  calculous,  and  if  but  one  kidney  is  affected,  whether  the 
other  is  .healthy. 


KID]SfEy    CALCULI.  559 

The  seat  of  pain  and  particularly  the  location  of  tenderness  on 
palpation  are  valuable  in  determining  the  kidney  affected.  The 
passage  of  normal  urine  free  from  blood  or  pus  during  attacks  of 
renal  colic  points  to  the  existence  of  a  healthy  kidney,  though  the 
absence  of  this  sign — i.e.,  the  passage  of  purulent  blood-stained 
urine — does  not  necessarily  show  that  both  kidneys  are  affected, 
since  the  obstruction  in  the  ureter  of  the  affected  side  may  not 
be  complete.  When  there  is  pyuria  and  an  operation  is  contem- 
plated, the  question  may  be  settled  by  the  use  of  the  catheterizing 
cystoscope. 

The  final  diagnosis  of  kidney  calculus,  and  this  is  always  justi- 
fiable when  the  integrity  of  the  kidney  is  seriously  threatened  and 
when  the  patient's  health  is  progressively  failing,  is  direct  exploration 
of  the  kidney  pelvis  by  means  of  a  lumbar  nephrotomy. 

Prognosis. — In  the  absence  of  symptoms  of  obstruction  or  infec- 
tion the  prognosis  of  kidney  stone  is  favorable.  Thfe  foreign  body 
may  remain  years  in  the  pelvis  or  calices  of  the  kidney,  causing  no 
sympto-ms  other  than  occasional  haematuria  or  perhaps  pain,  and  not 
seriously  affecting  the  secreting  substance  of  the  organ.  When  ob- 
struction develops,  if  it  is  transitory-,  due  to  the  passage  of  a  stone 
into  the  bladder,  and  is  completely  relieved  by  the  escape  of  the 
calculus,  the  urine  not  persistently  showing  albumin  and  hyaline 
casts,  the  prognosis  is  still  favorable.  When  the  obstruction  is  not 
promptly  relieved,  but  becomes  chronic,  the  prognosis  as  to  the  integ- 
rity of  the  kidney  is  grave.  When  infection  takes  place,  the  prog- 
nosis is  always  grave  unless  prompt  operation  is  practised.  The 
combination  of  obstruction  and  infection  imperatively  calls  for  opera- 
tive interference. 

Treatment. — The  preventive  treatment  of  kidney  calculus  is  indi- 
cated when  the  passage  of  sand  or  gravel,  or  a  microscopic  examina- 
tion of  the  urine,  shows  that  there  is  an  excess  of  solid  constituents. 
In  case  the  sediment  or  sand  is  made  up  of  uric  acid,  out-of-door  ex- 
ercise, abstinence  from  alcoholic  drinks,  baths  and  surface  friction, 
careful  regulation  of  the  diet,  and  the  ingestion  of  large  cjuantities  of 
water,  particularly  Carlsbad,  Friederichshall,  and  Londonderry,  are 
indicated. 

When  the  sediment  is  made  up  of  calcium  oxalate,  in  addition  to 
exercise,  diet,  and  diluents,  nitrohydrochloric  acid  is  of  service.  De- 
posits from  alkaline  urine  require  treatment  directed  either  against 
alkaline  dyspepsia  or  local  infection. 

Patients  subject  to  lithiasis  should  eat  sparingly,  should  especially 
avoid  dark  meats,  sugars,  highly  seasoned  food,  rhubarb,  tomatoes. 


560  GESriTO-UKINAKY   DISEASES   AXD   SYPHILIS. 

asparagus,  and  strawberries,  Burgundy,  champagne,  and  malt  liquors. 
They  should  drink  freely  of  pure  waters,  which  by  decreasing  the 
proportion  of  salts  in  the  urine  lessen  the  formation  of  new  calculous 
material,  and  by  increasing  the  volume  of  urine  aid  in  the  discharge 
of  any  that  has  already  been  deposited  in  the  kidney.  Potassium 
citrate,  lithium  carbonate,  and  sodium  phosphate  are  the  most  valu- 
able alkaline  diuretics.  These  drugs  may  be  given  in  doses  of  from 
five  to  twenty  grains  three  to  six  times  a  day  w^ell  diluted.  Moderate 
exercise  is  highly  desirable,  but  it  should  not  be  carried  to  the  point 
of  extreme  fatigue  or  excessive  perspiration.  All  excesses  should 
be  avoided,  especially  those  which  may  be  followed  by  gastro-intes- 
tinal  or  hepatic  disturbances. 

Palliative  treatment  for  severe  pain,  particularly  that  characteristic 
of  renal  colic,  is  mainly  limited  to  the  free  use  of  anodynes.  The 
methods  of  using  anodynes,  and  the  doses,  have  already  been  de- 
scribed under  Diseases  of  the  Ureter. 

Nephrolithotomy. — The  absolute  indications  for  the  perform- 
ance of  nephrolithotomy  are  harassing,  persistent  pain,  with  frequent 
overwhelming  exacerbations,  yielding  only  to  the  almost  continuous 
administration  of  anodynes,  hydronephrosis,  pyonephrosis,  hyaline 
casts,  albumen  in  the  urine,  and  anuria.  The  route  chosen  is,  with 
few  exceptions,  the  lumbar  one.  The  single  advantage  presented  by 
the  abdominal  incision  is  that  it  allow^s  of  exploration  of  both  kidneys. 
The  incision  for  exposing  the  kidney  is  that  already  described.  (Fig. 
181.)  In  fat  patients  it  is  not  easy  to  find  the  tw^elfth  rib  by  pal- 
pation ;  in  these  the  ribs  should  be  counted  from  above  downward. 
The  patient  is  placed  either  on  his  sound  side  in  the  half  ventral  decu- 
bitus with  a  roll  beneath  the  loin,  or  in  the  full  ventral  decubitus  with 
Edebohls'  air-cushion  eight  inches  in  diameter  lying  with  its  centre  of 
maximum  pressure  a  little  above  the  umbilicus.  The  incision  is  car- 
ried from  the  angle  made  by  the  tw^elfth  rib  and  the  erector  spinas 
muscle — i.e.,  from  the  lower  border  of  the  twelfth  rib  tw^o  inches  from 
the  middle  line  of  the  back,  downward  and  forward  for  four  inches 
tow^ards  the  anterior  superior  spinous  process  of  the  ileum.  The  in- 
cision is  carried  through  the  anterior  portion  of  the  latissimus  dorsi 
and  the  upper  part  of  the  serratus  posticus  inferior.  The  fascia  cov- 
ering the  erector  spinae  muscle  should  not  be  opened.  The  external 
and  the  internal  oblique  muscles  are  successively  cut  through  ;  betw^een 
the  latter  and  the  transversalis  (lumbar)  fascia  the  last  dorsal  nerve 
and  intercostal  artery  are  usually  encountered  ;  the  former  should  be 
preserved  if  possible.  The  outer  border  of  the  quadratus  lumborum 
muscle  is  then  retracted  and  the  anterior  layer  of  the  lumbar  fascia 


KIDNEY    CALCULI. 


561 


and  the  fascia  transversalis  are  divided,  exposing  the  fatty  capsule. 
If  the  first  incision  does  not  allow  of  full  exposure  of  the  kidney  to 
both  palpation  and  inspection,  it  should  be  enlarged  both  upward  and 
downward.  The  perinephric  fat  is  opened  widely,  and  the  kidney  is 
thoroughly  exposed  through  its  entire  surface  and  Is  drawn  well  into 
the  wound  by  traction  on  the  perinephric  capsule,  supplemented,  when 
the  ventral  decubitus  and  the  air-cushion  are  used,  by  so  pulling  the 
patient's  ankles  that  the  air-cushion  placed  beneath  the  abdomen  is 
rolled  from  below  upward.  The  kidney  is  then  palpated  by  the  fmgers 
of  the  two  hands  placed  on  either  side,  special  attention  being  devoted 

Fig.  181. 


Lines  of  incision  for  operations  on  tlie  kidney  by  the  lumbar  route.  Heavy  black  line  shows 
the  usual  incision.  Dotted  line  indicates  the  prolonged  incision  for  exploration  when  more  room 
is  needed  or  for  operations  on  the  ureter. 


to  the  hilum  and  to  the  two  extremities.  If  the  calculus  cannot  be  de- 
tected by  this  means, — and  this  may  well  be  the  case,  since  even 
after  the  kidney  has  been  removed  from  the  body  palpation  has 
failed  to  detect  a  stone  in  its  substance, — an  incision  should  be  made 
through  the  kidney-substance.  The  incision  which  will  cause  the  least 
possible  hemorrhage  must  be  made  in  the  line  of  separation  of  the 
two  vascular  systems  and  must  not  be  angled  towards  the  centre  of 
the  kidney.  Usually  this  vascular  area  lies  parallel  to  BrodePs  white 
line  and  one  centimetre  away  from  it  towards  the  posterior  surface 
of  the  organ.  (Fig,  182.)  The  bleeding  is  often  alarmingly  pro- 
fuse, but  is  usually  checked  by  packing  or  the  use  of  hot  water. 

^  36 


562 


GENITO-ITRINARY    DISEASES   AND   SYPHILIS. 


Fig.  182. 


The  kidney  pedicle  may  previously  be  clamped  either  by  the  fingers 
of  an  assistant  or  by  a  padded  clamp  made  for  the  purpose,  but  this 
is  not  essential.  The  incision  should  be  large  enough  to  permit  the 
finger  to  be  introduced  into  the  pelvis.  The  cavity  of  the  latter  can 
now  be  thoroughly  explored,  and  this  exploration  may  be  aided  at 
times  by  a  metal  sound.    This  instrument,  however,  must  be  used  with 

great  care.  Many  surgeons  still  rec- 
ommend— in  place  of  incision — ex- 
ploration of  the  kidney  pelvis  by 
means  of  puncture  with  a  needle. 
Kelly  advises  distention  of  the  renal 
pelvis  by  means  of  a  ureteral  catheter 
and  an  antiseptic  solution  before 
opening  into  its  substance.  Thus 
Brodel's  line  is  made  more  promi- 
nent, and  sacculations  of  the  cortex 
may  be  more  readily  detected.  The 
gush  of  fluid  also  denotes  that  the 
pelvis  has  been  opened.  The  pelvis 
and  calyces  are  explored  by  a  stone 
searcher,  such  as  is  used  for  the  ex- 
ploration of  the  bladder  of  children. 
After  exploration  of  the  calyces  and 
pelvis,  the  ureter  should  always  be 
examined  by  means  of  a  ureteral 
catheter. 

The  stone,  having  been  found,  is 
readily  removed,  provided  it  be  small 
and  fairly  regular  in  shape.  For  this 
purpose  either  the  scoop  or  forceps 
is  employed.  Branching,  coral-like 
stones  may  require  fragmentation. 
Stones  deeply  placed  in  the  pelvis 
may  be  thrust  up  by  pressure  of 
the  fingers  working  from  the  out- 
side. Mortar-like  concrements  may  be  removed  by  the  douche  and 
scoop. 

After  extracting  the  entire  calculus  it  is  well  to  flush  out  the  pelvis 
and  calyces  with  a  stream  of  normal  saline  solution  flowing  under 
strong  pressure  (eight  feet)  from  a  comparatively  large  nozzle.  The 
kidney-wound  is  then  sutured,  usually  by  No,  2  mattress  chromicized 
or  iodized  catgut  passed  through  the   capsule  and  kidney-substance 


Lateral  view  of  kidney,  b-b',  BriJdel's 
white  line;  a-a',  mid-line  of  kidney;  c-c', 
line  of  incision.     (Brodel.) 


KIDNEY   CALCULI. 


563 


down  to  the  pelvis  or  the  walls  of  a  dilated  calyx,  but  not  including 
the  mucous  membrane.  These  sutures  are  tied  down  with  moderate 
tension,  and,  providing  they  have  been  placed  deeply,  effectually  stop 

Fig.  183. 

?  o    S   t    e     r' 


A.  The  proper  position  for  tin- incision.     (Brodel.)    JB.  Brodel's  white  line. 

bleeding.  In  the  absence  of  renal  infection,  the  kidney-wound  is  not 
drained.  If  the  perinephric  tissue  has  been  widely  separated  to  insert 
sutures,  as  in  the  treatment  of  floating  kidney,  the  parietal  wound  is 
closed  by  careful  suture 
of  the  muscles  with  chro- 
micized  catgut.  A  drain- 
age-tube should  be  carried 
to  the  kidney-wound  in 
the  majority  of  cases. 

When  the  secreting 
substance  of  the  kidney 
has  disappeared  and  is 
represented  simply  by  a 
sac  in  which  a  large  calcu- 
lus is  contained,  nephrec- 
tomy is  indicated.  This, 
as  a  rule,  should  be  per- 
formed as  a  second  oper- 
ation,— i.e.,  some  weeks 
or  months  after  removal 
of    the    stone    and    after 

takmg      every     means     of  Method  of  suturing  split  kidney.    (Broth 

making  certain  that  there 

is  practically  no  secreting  kidney-substance  left  on  tlic  affected  side, 

and  that  the  other  kidney  is  competent  to  act  for  both. 


564  GENITO-UEHsTAKY   DISEASES   AND    SYPHILIS. 

When  infection  has  taken  place,  the  parietal  incision  is  the  same 
as  that  for  nephrolithotomy,  but  the  incision  into  the  kidney  is  made 
at  the  thinnest  and  most  accessible  portion  of  the  tumor.  Since 
infection  is  usually  complicated  by  pyelonephrosis,  there  may  be  a 
large  sac  with  diverticula,  making  the  finding  and  removal  of  a  stone 
extremely  difficult.  It  is  in  these  cases  particularly  that  the  sound  is 
serviceable.  It  often  happens  that  the  calculi  are  either  not  found  at 
all,  or,  if  found,  are  only  in  part  removed. 

In  the  after-treatment  of  these  w^ounds  lumbar  drainage  is  always 
indicated.  Fistulse  are  prone  to  persist  in  the  track  of  the  drainage- 
tubes. 

As  a  means  of  surely  removing  the  calculi  and  avoiding  the  per- 
sistence of  fistulse,  primary  nephrectomy  has  been  proposed  in  cases 
of  calculous  pyonephrosis,  particularly  when  the  sac  formed  is  large. 
The  operative  statistics  scarcely  justify  this  procedure,  except  when 
the  kidney  has  become  converted  into  a  suppurating  sac. 

Nephrolithotomy  performed  before  the  advent  of  suppuration  is 
attended  by  a  mortality  of  less  than  four  per  cent.  After  suppuration 
the  mortality  is  much  greater,  and  a  large  percentage  of  cases  are 
troubled  by  permanent  fistulse. 

Duplay  and  Reclus  particularly  insist  upon  the  importance  of 
operating  promptly  in  cases  of  calculous  anuria.  They  hold  that  this 
complication  is  usually  recurrent,  since  it  is  an  almost  certain  proof 
of  bilateral  lesion.  After  a  trial  of  prolonged  hot  baths,  warm  injec- 
tions, abundant  ingestion  of  diluents,  massage  of  the  ureter,  the  use 
of  a  continuous  current  of  electricity,  and  profound  ansesthetization, 
should  anuria  persist  operation  is  indicated.  Forty-eight  hours  should 
be  the  longest  time  allowed  for  these  palliative  measures.  Calculous 
anuria  is  spontaneously  relieved  in  twenty-eight  and  five-tenths  per 
cent,  of  cases.  Sixty-six  and  six-tenths  per  cent,  of  operative  cases 
recover.     (Legueu.) 

The  great  difficulty  in  these  cases  is  to  discover  the  seat  of  ob- 
struction :  palpation,  the  history  of  the  case,  and  ureteral  catheteriza- 
tion and  the  X-ray  may  determine  this.  The  incision  should  be  the 
lumbar  one,  and  the  whole  of  the  ureter  should  be  exposed  if  this  is 
necessary. 

It  frequently  happens  that  persistent  renal  symptoms,  particularly 
hsematuria,  pain,  and  recurrent  colic,  are  entirely  cured  by  nephrotomy, 
even  though  no  stone  or  other  cause  for  symptoms  be  found  at  oper- 
ation. This  is  so  well  recognized  that  the  operation  is  indicated  by 
the  wearing  persistence  of  symptoms  which  do  not  yield  to  conserva- 
tive treatment. 


CHAPTER  XVI. 

SUPPURATIVE    DISEASES    OF    THE    KIDNEY. 

The  suppurative  diseases  of  the  kidney  may  be  arranged  in  two 
groups..  In  the  first  group  belong  those  suppurations  the  microbes  of 
which  enter  the  kidney  through  the  artery,  vein,  or  lymphatic  chan- 
nels, or  extend  by  contiguity  from  the  perinephric  tissuQ.  In  the 
second  group  are  those  suppurations  which  are  due  to  ascending 
infection  along  the  ureter. 

Haematogenous  infection  of  the  kidney  is  nearly  always  secondary 
to  pyogenic  foci  elsewhere.  Jaffe  reports  five  metastatic  kidney  ab- 
scesses in  which  the  primary  foci  were  furuncle,  carbuncle,  tonsillar 
abscess,  and  parotiditis.  Either  ulceration  or  internal  suppuration 
may  furnish  the  germs,  but  usually  they  are  found  in  connection  with 
general  septicaemia,  pyaemia,  or  Ulcerative  endocarditis.  Exception- 
ally it  is  impossible  to  locate  a  primary  focus  ;  in  such  cases  we  must 
assume  that  micro-organisms  circulating  in  the  blood  have  attacked 
the  kidneys  first. 

.  It  has  been  conclusively  shown  that  septic  material  ascending  the 
vena  cava  may  enter  the  kidney  and  produce  suppuration. 

Traumatic  suppuration  of  the  kidney,  unless  the  result  of  a  pene- 
trating wound,  must  be  classed  with  haematogenous  infections,  since, 
in  the  absence  of  bacteria,  concussion  or  contusion  of  tissue  cannot 
produce  suppuration.  It  is  evident,  however,  that  the  injury  prepares 
a  suitable  culture-field  for  circulatory  micro-organisms.  In  the  trau- 
matic cases  but  one  kidney  is  usually  affected,  and  there  is  frequently 
perinephric  suppuration. 

It  is  often  impossible  to  distinguish  between  lymphatic  infection 
and  infection  due  to  extension  by  contiguity.  As  causes  of  secondary 
infection  may  be  mentioned  appendicitis,  perityphlitis,  parametritis, 
caries  of  the  vertebrae,  sacrum,  or  pelvis,  deep  colonic  ulceration, 
abscess  of  the  liver  or  spleen,  subphrenic  abscess,  and  urinary  in- 
filtration (rare).  All  these  inflammations  may  extend  to  the  kidney, 
involving  both  this  gland  and  its  fatty  capsule. 

The  micro-organisms  commonly  causative  of  renal  suppuration 
are  the  bacterium  coh  commune,  the  staphylococcus  aureus,  the  strep- 

565 


566  GEiSriTO-UIlINARY   DISEASES  AND   SYPHILIS. 

tococcus  pyogenes,  and  the  proteus  Hauseri.  Exceptionally  infection 
is  due  to  the  gonococcus,  the  bacillus  typhi,  the  diplococcus  pneu- 
monise,  the  tubercle  bacillus  (?),  actinomyces,  and  the  micro-organ- 
isms of  acute  infectious  diseases.  It  should  be  borne  in  mind  that 
pyelitis  is  common  in  the  course  of  the  various  infectious  diseases, 
and  may  become  membranous. 

Several  important  facts  must  be  emphasized  in  relation  to  the 
renal  suppurations  which  result  from  ascending  infection.  Obstruc- 
tion in  the  urethra,  bladder,  or  ureter  which  interferes  with  the  out- 
flow of  urine  produces  conditions  very  favorable  to  infection,  though 
it  will  not  in  itself  cause  suppuration.  An  aseptic  ligation  of  one  ureter 
causes  atrophy  of  the  kidney,  but  a  septic  ligation  gives  rise  to  sup- 
puration.^ Traumatism,  alteration  in  the  character  of  the  urine,  or  the 
elimination  of  irritating  drugs,  such  as  cantharides,  produces  conges- 
tion, but  never  septic  inflammation.  All  causes  which  occasion  acute 
or  chronic  congestion  predispose  to  infection. 

Clinically,  obstruction  and  the  consequent  alterations  in  the  urine 
are  the  conditions  which  most  frequently  render  the  kidney  and  its 
excretory  channels  favorable  culture-media  for  pyogenic  micro-organ- 
isms. As  a  rule,  the  healthy  mucous  membrane  of  the  uro-genital  tract 
resists  septic  infection,  but  it  will  not  always  do  so,  nor  is  it  necessary 
that  there  should  be  obstruction  in  order  that  septic  matter  in  the 
bladder  may  enter  the  ureters  and  ascend  into  the  pelvis  of  the 
kidney.  It  has  been  experimentally  shown  (Lewen  and  Goldschmidt) 
that  substances  introduced  into  the  normal  bladders  of  animals  may 
ascend  to  the  kidneys.  It  is  probable  that  under  certain  circum- 
stances intestinal  bacteria  may  obtain  an  entrance  into  the  kidneys 
without  any  discoverable  break  in  the  continuity  of  the  tissues. 

Micro-organisms  are,  then,  the  invariable  causes  of  renal  suppu- 
rations, and  the  chnical  causes  of  congestion  can  do  no  more  than 
make  the  tissues  susceptible.  While  it  is  true  that  individual  sus- 
ceptibility and  local  predisposition  render  one  person  more  liable  to 
suppuration  than  another,  it  must  not  be  forgotten  that  bacterial 
virulence  may  be  so  pronounced  that  the  most  healthy  tissues  cannot 
resist  infection. 

The  methods  by  which  bacteria  may  reach  the  kidneys  from 
below  are — through  the  urine  by  means  of  antiperistaltic  movements 
of  the  ureters ;  by  extension  along  the  mucous  membrane  or  the 
lymph-channels  of  the  ureters ;  by  penetration  into  the  pelvis  or 
ureter  from  the  tissues  surrounding  the  urinary  tract  (either  by  a 
rupture  of  an  abscess  into  the  pelvis  or  the  ureter,  or  by  emigration 
of  the  micro-organisms  through  the  walls). 


SUPPURATIVE   DISEASES   OP   THE    KIDNEY.  567 

The  clinical  causes  of  spontaneous  suppuration  of  the  kidney  are — 
the  acute  infectious  diseases,  exposure  to  cold  and  wet,  traumatism, 
stricture  of  the  urethra,  enlargement  of  the  prostate,  tuberculosis  or 
malignant  disease,  gout,  irritation  from  drugs,  such  as  turpentine  or 
cantharides,  and  renal  calculus.  Age,  sex,  and  occupation  affect  the 
development  of  suppurative  kidney  disease  only  so  far  as  they  are 
associated  with  predisposing  causes.  Thus,  pyelitis  is  common  in 
old  men  because  of  prostatic  enlargement,  and  in  young  women  be- 
cause they  frec^uently  suffer  from  parametritis. 

In  accordance  with  its  location  and  clinical  course  renal  suppura- 
tion is  termed  pyelitis,  pyonephrosis,  pyelonephritis,  and  suppurative 
nephritis. 

Pyelitis,  or  inflammation  of  the  kidney  pelvis,  may  be  secondary 
to  nephritis  (descending),  or  to  ureteritis  (ascending),  or  rarely  to 
perinephritis  (contiguity) ;  the  ascending  inflammation  is  the  common 
form. 

The  most  frequent  predisposing  and  exciting  causes  of  pyelitis  are 
— (a)  the  infectious  diseases  ;  whether  in  these  cases  the  local  inflam- 
mation is  due  to  toxins  or  to  alterations  in  the  urine  has  not  been  de- 
termined ;  (6)  traumatism,  a  rare  but  undoubted  cause ;  (c)  exposure 
to  cold ;  (d)  drug  irritation,  as  from  the  irritating  diuretics,  the  bal- 
sams, the  ethereal  oils ;  (e)  nephritis,  particularly  the  interstitial  ne- 
phritis of  the  gouty  ;  (/)  venous  congestion,  due  either  to  general 
stasis  or  to  local  stasis,  as  in  chronic  valvulitis,  pregnancy,  floating 
kidney,  abdominal  tumor ;  (g)  perinephric  inflammation  ;  (h)  mechani- 
cal irritation  of  gravel  or  calculus ;  (i)  tubercle,  malignant  disease, 
parasites ;  (j)  and,  most  important  of  all,  cystitis,  particularly  when 
it  is  associated  with  obstruction. 

Pyelitis  is  usually  bilateral.  It  varies  in  degree  from  a  superficial 
catarrhal  inflammation  to  a  deep  infiltrating  destructive  process.  In 
the  absence  of  infection  there  is  often  a  congestion  of  the  mucous 
membrane  of  the  pelvis  unassociated  with  desquamation  of  epithe- 
Kum  or  suppuration.  Such  a  condition  may  be  caused  by  irritating 
conditions  of  the  urine. 

Catarrhal  pyelitis  may  be  acute  or  chronic.  In  the  acute  form  the 
mucous  membrane  is  swollen  and  congested  ;  there  are  patches  of 
desquamation;  in  severe  cases  the  surface  is  covered  with  thick 
mucus  mixed  with  blood,  in  which  the  crystals  of  the  urinary  salts 
are  deposited.  In  chronic  pyelitis  the  mucous  membrane  is  dark  in 
color,  there  is  a  serous  infiltration  of  the  submucoid  tissues,  with 
interstitial  overgrowth,  many  small  mucus-cysts  may  be  formed,  and 
in  some  cases  the  lymph-follicles  become  much  enlarged  and  promi- 


568  GENITO-UKINAKY   DISEASES  AND   SYPHILIS. 

nent  (pyelitis  granulosa).  The  surfr.ce  is  generally  covered  with  a 
tenacious  altered  mucus,  and  there  is  general  desquamation  of  epithe- 
lium. Ulceration  may  be  present,  which  may  extend  through  the 
coats  of  the  pelvic  wall,  giving  rise  to  abscesses  or  even  to  infiltration 
of  urine.  Any  pyelitis  may  become  membranous,  particularly  when 
ammoniacal  fermentation  has  taken  place.  Indeed,  a  strictly  catarrhal 
pyelitis  is  quite  rare. 

When  the  pus  of  pyehtis  blocks  a  ureter,  pyonephrosis  or  pyelo- 
nephritis results.  Parenchymatous,  or  more  commonly  interstitial, 
nephritis  is  frequently  caused  by  pyelitis  ;  the  contracted  kidney  of 
pyelitis,  however,  differs  from  a  primary  contracted  kidney  in  that  the 
preponderance  of  fibrous  overgrowth  is  in  the  medullary  substance 
instead  of  in  the  cortex.  Amyloid  degeneration  may  occur  in  one  or 
both  kidneys  when  suppuration  is  profuse  and  long  continued. 

Symptoms. — In  many  cases,  as  is  evident  from  the  hst  of  causes,  the 
symptoms  of  a  pyelitis  are  lost  in  those  of  the  antecedent  disease.  In 
simple  congestion  of  the  pelvis  pain  in  the  loins  and  frequent  urina- 
tion are  the  only  symptoms. 

In  acute  catarrhal  purulent  pyelitis  the  pain  is  often  severe,  and 
may  present  acute  exacerbations  ;  the  kidneys  are  tender  on  pressure, 
and  frequency  of  urination  is  marked.  The  quantity  of  urine  is 
usually  decreased,  and  "exceptionally  reflex  anuria  may  supervene. 
The  pain  is  increased  by  motion,  by  deep  respiration,  or  by  coughing, 
and  may  be  reflected  down  into  the  penis  and  testicle  or  up  towards 
the  shoulder. 

Vomiting  is  not  uncommon.  Fever  develops,  and  there  may  be 
chihs  foHowed  by  profusie  perspiration.  As  a  rule,  the  kidneys, 
though  tender,  are  but  little  enlarged  in  acute  pyelitis. 

The  urine  is  generally  acid,  and  contains  a  trace  of  albumen,  de- 
generated epithelium,  hyahne  casts,  and  often  pus  and  blood. 

Acute  pyelitis  and  pyelonephritis,  due  to  the  colon  bacillus,  are 
common,  though  usually  overlooked  in  infancy  ;  pyuria  of  non-vesical 
origin,  renal  tenderness,  chills,  fever,  and  gastro-intestinal  disturbances 
are  characteristic  symptoms. 

In  chronic  pyehtis  the  symptoms  are  usually  less  pronounced. 
The  pains  are  not  so  marked,  nor  are  the  glands  so  tender  on  press- 
ure. Fever,  if  present,  is  likely  to  be  intermittent.  The  kidney  is 
not  palpably  enlarged  unless  there  is  pyonephrosis.  There  is  a  general 
impairment  of  health. 

The  urine  is  increased  in  amount,  is  acid  or  neutral,  and  contains 
nucleo-albumen,  pus,  and  epithelium  in  abundance ;  blood  is  rare. 
As  in  the  acute  form,  hyaline  casts  are  common,  but  in  a  pure  pye- 


SUPPUEATIVE   DISEASES   OF   THE   KIDNEY.  569 

litis  granular  casts  are  rarely  seen.  If  only  one  kidney  is  affected, 
there  may  be  periods  when,  owing  to  obstruction  of  the  diseased 
pelvis,  the  urine  will  be  normal.  Calculi  not  infrequently  form  in 
chronically  inflamed  pelves.  Many  cases  of  chronic  pyelitis  are  over- 
looked till  irremediable  kidney  disorganization  has  occurred. 

Diagnosis. — Pyelitis  must  be  distinguished  from  renal  and  from 
vesical  inflammation.  In  pyelitis  the  albumen  is  dependent  upon 
the  blood  and  pus,  in  nephritis  it  is  essential.  Granular  casts  are 
usual  in  kidney  disease,  they  are  not  found  in  pyelitis.  The  large 
amount  of  nucleo-albumen  is  cjuite  distinctive  of  pyelitis.  The  leuco- 
cytes in  the  urine  of  nephritis  are  often  mononuclear,  those  of  pye- 
litis are  polynuclear.  The  pain  of  nephritis  is  insignificant,  while 
acute  severe  pain  occurs  in  nearly  all  cases  of  pyelitis. 

Cystitis  suppurates  more  freely  than  pyelitis,  and  the  urine  is  more 
likely  to  be  alkaline  and  contains  a  much  smaller  percentage  of 
albumen  (one-tenth  per  cent,  as  contrasted  with  three  times  as 
much  in  pyelitis.  Rosenfeld).  A  cystoscopic  examination  will  prove 
the  presence  of  inflammation,  and  ureteral  catheterization  will  show 
that  the  urine  contains  no  pus  till  it  reaches  the  bladder.  Such  an 
examination  may  be  required  before  the  origin  of  pus  can  be  positively 
determined.  The  importance  of  this  becomes  evident  when  it  is  real- 
ized that  in  the  absence  of  ureteral  obstruction  polyuria  and  pyuria  are 
the  most  constant  and  reliable  signs  of  chronic  pyelitis.  Bazy  regards 
nocturnal  pollakiuria  as  the  most  important  of  all  signs  for  the  differ- 
entiation of  pyelitis. 

Prognosis. — Acute  congestion  and  chronic  congestion  of  the  kidney 
pelvis  are  dangerous  only  because  they  predispose  to  infection.  Acute 
catarrhal  or  purulent  pyelitis  is  generally  self-limited  unless  the  in- 
fection has  spread  to  the  kidney-substance,  the  period  of  disease 
varying  from  a  few  days  to  a  few  weeks.  The  prognosis  and  dura- 
tion of  chronic  pyelitis  depend  obviously  upon  the  cause.  When 
the  disease  develops  without  appreciable  cause,  or  when  it  is  asso- 
ciated Avith  incurable  obstruction  or  an  inveterate  gouty  diathesis,  the 
prognosis  must  be  guarded. 

Treatment. — The  treatment  of  pyelitis  varies  in  accordance  with 
the  cause,  and  is  also  dependent  in  a  measure  upon  the  character 
of  the  inflammation.  Slight  cases,  such  as  those  which  develop  after 
the  exanthemata,  are  treated  by  rest,  liquid  diet,  and  the  ingestion 
of  diluents.  The  natural  tendency  of  this  form  of  inflammation  is 
towards  recovery.  When  the  symptoms  are  sufficiently  severe  to 
excite  some  constitutional  reaction  and  to  cause  local  pain,  counter- 
irritation,  local  depletion,  hot  baths,  the  administration  of  soothing  or 


570  GENITO-URINARY    DISEASES   AND    SYPHILIS. 

stimulating  diuretics,  and  careful  attention  to  the  condition  of  the  skin 
are  indicated.  Pain  should  be  relieved  by  morphine  given  hypo- 
dermically.  Inflammation  due  to  mechanical  causes,  such  as  calculus 
or  stricture,  prostatic  enlargement,  or  any  obstruction  to  the  free  flow 
of  urine,  can  be  cured  only  by  surgical  intervention.  Should  this  be- 
come necessary  in  the  course  of  acute  pyelitis,  it  must  be  borne  in 
mind  that  there  is  always  great  danger  of  converting  a  simple  pyelitis 
into  a  pyelonephritis  or  "  surgical  kidney  ; "  hence  every  antiseptic 
precaution  should  be  taken. 

If  the  bladder  be  the  seat  of  inflammation,  vigorous  treatment  of 
the  cystitis  may  effect  a  cure.  Cabot  has  pointed  out  the  value  of 
permanent  catheterization. 

The  operative  procedures  should  be  preceded  by  the  administra- 
tion of  urinary  antiseptics, — namely,  salol  and  boric  acid ;  urotropin 
or  benzoic  acid  should  be  given  when  the  urine  is  alkaline. 

The  development  of  pyelitis  as  a  complication  of  any  obstructive 
lesion  of  the  urinary  tract,  regardless  of  its  seat  or  cause,  is  a  suffi- 
cient ground  for  operative  interference  when  this  offers  any  promise 
of  permanently  overcoming  the  obstruction.  The  operation  should 
be  performed  early,  since  pyelitis  associated  with  obstruction  means 
inevitable  destruction  of  the  secreting  substance  of  the  kidney. 

Kelly,  Pawlik,  and  others  have  treated  chronic  pyelitis  by  the 
mouth  administration  of  urinary  antiseptics  (salol  and  urotropin)  and 
diluents,  and  by  drainage,  instillation,  and  irrigation.  This  treatment, 
particularly  indicated  in  cases  dependent  upon  ureteral  strictures, 
has  also  been  efficient  in  those  cases  developed  as  a  consequence  of 
haematogenous  or  of  ascending  infection ;  in  the  latter  case  only  after 
the  cure  of  the  lesions  of  the  lower  tract.  Protargol,  in  one  to  five 
per  cent,  solution,  is  used  for  instillation,  the  same  drug,  1  to  2000, 
or  boric  acid,  1  to  500,  for  irrigation,  the  treatments  being  repeated 
twice  weekly  till  pus  has  disappeared  from  the  urine.  Thereafter 
prolonged  dietetic  and  hygienic  treatment  is  indicated.  When  a 
chronic  pyelitis  persists,  as  shown  by  urinary  examination  and  renal 
and  gastro-intestinal  symptoms,  in  spite  of  a  careful  dietetic  and  hy- 
gienic regimen  supplemented  by  diluents  and  urinary  antiseptics  given 
in  such  doses  as  not  to  disturb  the  stomach,  nephrotomy  is  indicated. 
This  is  performed  by  the  lumbar  route,  the  renal  pelvis  being  opened 
through  the  avascular  zone  of  the  kidney-substance.  Mechanical  causes 
of  obstruction  are  sought  for  and  removed,  and  the  pelvis  is  irrigated 
and  drained  through  ureteral  catheters. 

Pyonephrosis. — When  in  the  course  of  pyelitis  the  ureter  be- 
comes blocked,  pyonephrosis  develops.     The  same  condition  is  pro- 


SUPPUEATIVE    DISEASES    OF    THE    KIDjSTEY.  571 

duced  by  infection  of  hydronephrosis.  The  pelvis  becomes  rapidly 
distended,  and  ulceration  and  dilatation  of  the  cahces  occur.  When 
the  condition  is  permanent  the  entire  kidney  is  riddled  with  abscesses. 
The  obstruction  is  usually  incomplete. 

The  pelvis  may  rupture  early ;  later  rupture  may  take  place 
through  the  cortex ;  in  either  case  there  results  a  perinephric  ab- 
scess. Exceptionally  pus  may  become  inspissated,  and  extreme 
contraction  of  the  kidney  occur.  Pyonephrosis  may  give  rise  to 
general  metastasis,  but  this  is  rare.  Occasionally  the  kidney  forms 
adhesions  to  neighboring  organs  and  may  rupture  into  them. 

Symptoms. — In  cases  which  follow^  the  blocking  of  a  ureter  the  first 
symptom  is  usually  pain,  which  may  be  cohcky,  and  is  made  worse 
by  pressure  anteriorly,  but  is  often  relieved  by  pressure  posteriorly. 
Fever  with  chill  will  likely  be  the  first  symptom  in  a  case  in  which 
suppuration  occurs  in  a  hydronephrotic  sac.  The  quantity  of  urine 
bears  some  ratio  to  the  retention  ;  in  a  few  cases  anuria  is  produced 
by  reflex  inhibition,  though  this  is  usually  due  to  defect  or  absence 
of  the  other  kidney. 

A  tumor  may  form  in  the  loin,  tender  on  pressure,  fluctuating 
in  most  cases,  but  sometimes  doughy,  and  projecting  into  the  ab- 
dominal cavity.  The  tumor  is  often  not  perceptible.  It  will  be  dull 
on  percussion  in  the  flank,  but  the  presence  of  the  overlying  colon 
generally  suffices  to  make  the  note  on  abdominal  percussion  reso- 
nant ;  alternate  emptying  and  filling  of  the  colon  with  .air  or  liquid 
may  aid  in  establishing  a  diagnosis. 

If  the  pyonephrosis  is  unilateral,  pus  may  disappear  from  the 
urine  at  times  ;  if  bilateral,  the  pus  may  be  reduced  in  quantity  ;  but 
it  is  a  clinical  fact  that  in  some  cases  little  apparent  change  occurs  in 
the  c{uantity  of  pus  contained  in  the  urine. 

The  variations  in  the  quantity  of  pus  in  cases  of  pyelitis  are 
sometimes  marked,  so  that  a  sudden  reduction  of  pus  in  the  urine 
does  not  imply  obstruction  unless  it  is  coincident  with  a  reduction  in 
the  quantity  of  urine.  If  the  obstruction  is  permanent  and  the  other 
kidney  is  able  to  compensate,  the  quantity  of  urine  will  gradually  rise 
to  the  normal.  Irregular  fever,  with  a  high  evening  rise,  chills,  and 
the  constitutional  symptoms  of  internal  suppuration  are  present  in 
most  cases,  but  some  run  their  course  with  few  or  no  general  symp- 
toms. 

Diagnosis. — The  diagnosis  of  pyonephrosis  is  founded  upon  the 
presence  of  a  tumor  in  the  region  of  the  kidney  and  on  intermittent 
pyuria.  The  tumor  cannot  always  be  felt,  since  distention  may 
take  place  upward  towards  the  diaphragm.     When  perceptible  it  is 


572  GENITO-UEIXARY   DISEASES    AXD    SYPHILIS. 

rounded  in  form,  obscurely  fluctuating,  and  tender  on  pressure.  A 
pathognomonic  characteristic  of  the  tumor  is  its  variation  in  size^ 
dependent  upon  temporary  relief  of  obstruction  and  escape  of  the 
purulent  urine  contained  in  the  kidney  pelvis.  This  symptom  is 
closely  related  to  intermittent  pyuria;  when  the  peMs  of  but  one 
kidney  is  affected,  the  other  remainmg  healthy,  there  may  be  periods 
when  the  urine  is  absolutely  normal,  foUowed  by  periods  during 
which  there  is  marked  polyuria,  the  urine  containing  a  large  cpantity 
of  pus. 

Rayer  states  that  pyonephrosis  must  be  distinguished  from  mor- 
bid enlargements  of  the  spleen,  liver,  and  gall-bladder,  from  renal , 
tumors  due  to  causes  other  than  pyonephrosis,  such  as  hydronephro- 
sis, hemorrhage,  cancer,  tubercle,  or  cysts,  from  renal  abscess,  from 
tumors  of  the  suprarenal  capsule,  from  aortic  aneurism,  and  from 
faecal  impaction. 

A  differentiation  from  hydronephrosis  or  perinephric  abscess  is 
often  difficult.  Hydronephrosis  is  unattended  by  fever,  and  there 
is  usually  but  slight  pain  ;  continuous  or  intermittent  pyuria  is  absent. 
Perinephric  abscess  is  characterized  by  severe  pain,  rapid  extension 
of  the  tumor,  marked  constitutional  symptoms,  extreme  local  ten- 
derness, and  often  oedema  and  superficial  fluctuation.  The  urine 
may  or  may  not  contain  pus ;  the  thigh  is  often  flexed  upon  the 
abdomen.  At  times  a  chstinction  cannot  be  made.  This,  however, 
is  not  a  matter  of  great  importance,  since  the  three  conditions,  pyo- 
nephrosis, perinephric  abscess,  and  hydronephrosis,  practically  require 
the  same  treatment. 

The  distinction  of  pyonephrosis  from  aortic  aneurism  is  of  great 
importance,  since  were  aneurism  present  an  incision  for  nephrotomy 
might  result  fatally. 

Treatment. — Pyonephrosis,  dependent  as  it  necessarily  is  upon  in- 
fection and  obstruction,  is  amenable  only  to  mechanical  treatment. 
Ureteral  catheterization  when  successful  will  relieve  tension,  and  hence 
stop  septic  absorption,  and  may  in  some  cases  prove  curative  by 
enabling  the  surgeon  to  evacuate  the  pus  and  to  treat  the  renal  pelvis 
by  direct  instillation  and  irrigation.  When  this  procedure  is  inappli- 
cable, operation  is  indicated. 

AVhen  there  is  marked  narrowing  or  complete  blocking  of  the  ex- 
cretory channels,  associated  with  constitutional  symptoms  of  septic 
absorption,  operation  is  imperatively  indicated,  since  there  is  danger 
of  purulent  infiltration  and  destruction  of  the  secreting  portion  of  the 
kidney,  and  long-continued  suppuration  is  likely  to  produce  amyloid 
degeneration  of  the  opposite  kidney.     When  both  kidneys  are  dis- 


SUPPURATIVE    DISEASES   OF   THE    KIDNEY.  573 

eased,  nephrectomy  is  inadmissible,  even  should  this  be  indicated  by 
the  extent  of  local  infection.  It  happens  at  times  that,  as  a  result 
of  non-interference  and  because  of  complete  ureteral  obstruction, 
the  kidney  atrophies,  the  pus  which  it  contains  becomes  caseous,  and 
there  is  thus  effected  a  species  of  spontaneous  cure. 

The  operative  treatment  may  take  the  form  of  aspiration,  nephrot- 
omy, or  nephrectomy. 

Aspiration  gives  temporary  relief,  and  is  exceptionally  followed  by 
cure,  since,  as  the  result  of  relief  of  tension  and  consequent  conges- 
tion, the  obstruction  is  overcome  and  the  secretion  of  the  kidney  is 
again  poured  into  the  bladder.  Usually  a  more  radical  method  of 
treatment  will  be  required. 

Nephrotomy  consists  in  exposing  the  kidney  by  the  ordinary  lum- 
bar route,  opening  the  pelvis  through  the  parenchyma,  evacuating 
the  pus  and  urine,  and  removing  calculi  if  these  are  present.  The 
ureters  should  be  explored,  and  obstruction  should  be  remedied  by 
appropriate  treatment.  The  perinephric  tissues  are  thoroughly  cleaned 
and  drained  by  gauze,  the  suppurating  cavity  is  packed  with  gauze, 
and  a  thick,  absorbent  dressing  is  applied,  the  patient  being  placed  on 
an  oakum  mat.  In  twenty-four  hours  the  gauze  packing  in  the  pelvis 
of  the  kidney  is  replaced  by  a  large  drainage-tube,  and  the  perinephric 
packing  is  removed,  with  the  exception  of  two  or  three  small  strips. 

Nephrectomy  may  be  performed  as  a  primary  operation  when  the 
kidney  has  been  converted  into  a  thin,  pus-containing  sac  which  is 
not  very  adherent.  The  adhesions  are  often  dense,  sometimes  insur- 
mountable. It  has  happened  to  a  surgeon  as  experienced  as  Billroth 
to  tear  the  vena  cava  and  lose  his  patient  from  hemorrhage  in  the 
effort  to  remove  a  pyonephrotic  kidney.  It  is  safer  to  postpone  total 
removal  till  it  has  been  proved  that  nephrotomy  and  drainage  are  in- 
sufficient to  cure.  The  mortality  of  secondary  operations  is  lower 
than  that  for  primary  nephrectomy  in  this  class  of  cases. 

buplay  and  R.eclus  collected  one  hundred  and  six  cases  of  nephrot- 
omy performed  for  suppurative  disease  of  the  kidney  (pyelitis) ;  the 
mortality  was  thirteen  and  three-tenths  per  cent.  The  mortality  of 
nephrectomy  is  estimated  at  thirty-seven  and  five-tenths  per  cent. 
They  state  that,  even  when  patients  are  profoundly  cachectic,  opera- 
tion and  drainage  may  prolong  life  for  several  years.  This  result  is 
due  not  only  to  suppression  of  the  infecting  focus  from  which  are 
absorbed  toxins,  but  also  to  a  physiological  action  which  is  well  con- 
firmed. After  free  drainage,  portions  of  the  kidney  which  remain 
intact  are  able  to  resume  their  excretory  function.  After  nephrotomy 
a  fistula  persists  in  about  forty-five  and  six-tenths  per  cent,  of  cases. 


574  GENITO-URINARY    DISEASES   AND   SYPHILIS. 

This  is  often  due  to  long  postponement  of  the  operation.  In  second- 
ary nephrectomy  for  pyehtis  the  mortahty  in  twenty-four  cases  was 
five  and  nine-tenths  per  cent. 

Pyelonephritis. — This  term  signifies  septic  inflammation  of  the 
kidney  secondary  to  pyelitis.  It  is  the  ascending  form  of  renal 
suppuration.  The  descending  form  is  best  known  as  suppurative 
nephritis. 

The  predisposing  and  exciting  causes  of  pyelonephritis  are  the  same 
as  those  of  pyelitis  and  pyonephrosis.  It  is  merely  a  more  extensive 
and  more  dangerous  stage  of  pyelitis,  and  an  almost  unavoidable 
complication  of  pyonephrosis.  The  infection  extends  from  the 
cahces  into  the  uriniferous  tubules,  involving  the  parenchyma  of  the 
kidney,  and  converting  the  organ  into  a  mass  of  small  abscesses,  or 
perhaps  one  large  suppurating  sac.  The  name  "  surgical  kidney"  has 
been  applied  to  this  form  of  suppurative  disease,  because  it  has  been 
so  frequently  produced  by  the  use  of  infected  instruments. 

Pyelonephritis  is  apt  to  develop  rapidly  when  decomposing  urine 
is  retained  in  the  pelvis ;  it  may  be  caused  by  extension  of  inflam- 
mation in  the  absence  of  retention. 

In  the  early  stages  of  pyelonephritis  the  cortex  of  the  kidney  is 
thin,  and  the  capsule  is  adherent  to  the  surface  and  to  the  renal  tis- 
sue. When  it  is  stripped  from  the  kidney  numerous  small  abscesses 
are  opened ;  the  kidney  is  swollen,  soft,  and  congested.  Section 
shows  yellow  streaks,  the  distended  straight  tubules  running  from 
the  cortex  to  the  pyramids.  Between  these  streaks  the  renal  sub- 
stance seems  to  be  healthy.  The  pelvis  is  congested,  and  exhibits 
patches  of  ecchymosis,  or  even  of  ulceration.  Instead  of  small  sup- 
purating foci,  large  abscesses  may  form,  and  break  through  the  kidney 
capsule. 

Microscopically,  the  straight  tubules  are  dilated,  distorted,  and 
filled  with  epithelial  debris,  pus,  urinary  salts,  and  micro-organisms. 
The  veins  are  also  distended  with  partially  coagulated  blood  and  pus. 
This  is  in  marked  contrast  with  pyaemic  processes,  in  which  the  blood- 
clot  and  pus-formation  take  place  within  the  arteries.  The  Malpighian 
bodies  and  convoluted  portions  of  the  tubules  become  obliterated. 
The  fatty  capsule  is  infiltrated,  tough,  fibrous,  and  adherent  in 
chronic  inflammation,  or  it  may  become  infected  and  suppurate. 

The  colon  bacillus  is  the  usual  microbic  cause  of  an  ascending 
pyelonephritis. 

Symptoms. — Pyelonephritis  may  assume  the  acute  or  the  chronic 
form.  The  acute  form  is  characterized  by  the  sudden  onset  of  a 
chill,  followed  by  high  fever,  and  accompanied  by  severe  pains  in  the 


SUPPURATIVE    DISEASES   OF   THE    KIDNEY.  575 

loins.  There  is  often  delirium,  and  the  fever  may  rise  to  106°  or 
107°  F.,  or  even  higher. 

Usually  the  fever  is  continuous,  with  remissions.  The  patient 
passes  into  a  typhoid  state  ;  the  tongue  is  dry  and  heavily  coated ; 
there  are  rapid  emaciation,  often  an  extremely  irritable  condition  of 
the  stomach,  and  drenching  sweats.  There  may  be  persistent  vomit- 
ing and  hiccough.  Mental  dulness,  semi-consciousness  deepening  into 
coma,  and  finally  death,  follow. 

The  disease  is  usually  rapidly  fatal,  terminating  in  about  ten  days 
or  two  weeks. 

It  is  obvious  that  symptoms  of  acute  pyelonephritis  are  due  in  part 
to  septic  intoxication,  in  part  to  uraemia.  All  cases  do  not  end  fatally. 
The  fever  may  gradually  grow  less,  the  stomach  become  retentive, 
and  a  return  to  comparative  health  follow.  In  such  cases  it  seems 
probable  that  the  pus  has  been  so  placed  as  to  be  well  drained  into 
the  ureter,  or  that  it  has  become  caseous  and  encysted,  the  secreting 
substance  of  the  one  kidney  having  been  destroyed,  and  the  remain- 
ing kidney  having  assumed  double  duty. 

With  the  lessening  or  disappearance  of  fever  the  return  to  health 
is  the  exception,  not  the  rule.  The  pyelonephritis  is  more  likely  to 
become  chronic.  In  this  form  of  infiammation  the  temperature  may 
be  normal.     Commonly  it  is  slightly  and  persistently  elevated. 

Rayer  long  ago  pointed  out  that  the  chief  symptoms  of  chronic 
pyelonephritis  are  often  those  of  gastro-intestinal  irritation.  These 
are  chronic  dyspepsia,  a  dry  brown  tongue,  secretion  of  saliva  so 
scanty  that  sohd  food  is  refused,  constipation,  often  tympany,  some- 
times uncontrollable  diarrhoea.  The  patient  is  usually  extremely 
weak  and  depressed,  and  sleeps  badly.  These  symptoms  gradually 
become  more  marked,  and  progressive  emaciation,  extreme  suscepti- 
bility to  local  congestion  from  exposure  to  cold,  and  frequently  -inter- 
current febrile  attacks,  develop.  The  symptoms  are  due  to  uraemia 
and  infection  combined.  Locally  there  may  be  neither  pain  nor 
tumor,  and  the  patient  may  be  unaware  of  any  urinary  trouble. 

Diagnosis. — This  is  based  upon  the  presence  of  pus  in  the  urine, 
pain  and  tenderness  in  the  region  of  the  kidney,  the  presence  of  a 
tumor,  and  the  development  of  an  otherwise  inexplicable  gastro- 
intestinal catarrh.  In  the  absence  of  pyonephrosis,  there  are  usually 
polyuria  and  constant  pyuria.  Oliguria  is  an  ominous  sign.  The 
urine  is  alkaline.  Microscopic  examination  shows  hyaline  casts  and 
sometimes  fragments  of  renal  tissue.  Exceptionally  there  is  slight 
hsematuria ;  rarely  the  bleeding  is  free :  this  is  usually  due  to  cal- 
culus.    There  may  be  absence  of  both  spontaneous  and  provoked 


576  GENITO-TJEINAEY   DISEASES   AND   SYPHILIS. 

pain.  There  is  frequent,  often  painful,  urination,  especially  during 
acute  exacerbations  of  the  chronic  inflammation.  When  pyelone- 
phritis is  complicated  by  pyonephrosis  there  is  also  the  development 
of  a  swelling  which  may  exhibit  variations  in  size  ;  if  but  one  kidney 
is  affected  there  may  be  intermittent  polyuria  and  pyuria. 

The  diagnostic  characteristics  of  pyelonephritis  are  pyuria  and 
symptoms  of  septicaemia. 

The  differential  diagnosis  of  chronic  pyelonephritis  from  cystitis 
may  be  extremely  difficult.  Cystitis,  however,  does  not  produce 
the  constitutional  symptoms,  and  ureteral  catheterization  will  show 
the  absence  of  pus  from  the  urine  as  it  escapes  from  the  kidneys. 
Cystitis  and  pyelonephritis  are  often  associated.  In  such  cases  ure- 
teral catheterization,  by  showing  that  pus  comes  from  the  kidney, 
is  again  serviceable ;  moreover,  fever,  rapid  deterioration  in  health, 
and  pronounced  gastro-intestinal  symptoms  are  in  themselves  suffi- 
ciently characteristic  of  the  kidney  affection. 

The  symptoms  of  renal  tuberculosis  are  similar  to  those  of 
pyelonephritis.  Tubercular  family  history,  the  presence  of  tubercular 
infection  in  other  portions  of  the  genito-urinary  tract,  and  the  finding 
of  the  Koch  bacillus  will  point  to  the  nature  of  the  disease.  There 
is  often  mixed  infection  in  tubercular  nephritis. 

It  is  important  to  find  out  whether  both  kidneys  are  affected. 
This  will  be  determined  by  the  results  of  palpation  and  ureteral 
catheterization. 

Intermittent  pyuria  necessarily  points  to  the  existence  of  one 
healthy  kidney.  Hypodermic  injections  of  methyl-blue  are  some- 
times useful  in  determining  renal  permeabihty.  Healthy  kidneys 
eliminate  this  drug  partly  unchanged  and  partly  in  combination  rap- 
idly, unintermittently.  and  completely.  When  the  kidneys  are  dis- 
eased the  elimination  is  slow  and  intermittent.  When  it  is  impor- 
tant to  knovv^  whether  one  or  both  kidneys  are  diseased,  this  may 
be  determined  only  by  ureteral  catheterization  or  the  use  of  the 
segregator. 

Treatment. — The  preventive  treatment  of  pyelonephritis  is  partic- 
ularly important.  In  view  of  the  fatality  of  this  affection,  it  is  im- 
possible to  express  too  emphatically  the  necessity  for  asepsis  even 
in  so  trivial  an  operation  as  catheterization,  especially  when  after 
chronic  retention  the  urinary  tract  is  predisposed  to  infection. 

When  pyelonephritis  has  developed  it  should  be  treated  as  a 
combination  of  uraemia  and  septicaemia.  Licjuid  diet,  particularly 
milk,  the  administration  of  diuretics  and  of  diluents,  counter-irrita- 
tion over  the  kidneys, — in  acute  cases  by  dry  cups  followed  by  hot 


SUPPUEATIVE   DISEASES   OF    THE    KIDNEY.  577 

fomentations, — and  the  administration  of  laxatives,  are  indicated  as 
the  means  of  combating  uraemia.  Since  septicaemia  causes  death  by 
exhaustion,  the  administration  of  alcohol  well  diluted  and  of  as  much 
nourishment  as  can  be  assimilated  is  desirable.  Quinine  should  be 
avoided,  since  it  is  useless  in  small  doses,  and  in  full  doses  markedly 
congests  the  kidneys.  Small  doses  of  salol  and  boric  acid  are  ser- 
viceable, since  they  tend  to  prevent  ammoniacal  fermentation  in  the 
kidney  pelvis. 

When  pyonephrosis  develops  in  the  course  of  pyelonephritis,  or, 
even  in  the  absence  of  this,  if  symptoms  are  progressive,  nephrotomy 
with  free  drainage  is  indicated.  The  kidney  should  be  opened  into 
the  pelvis  on  its  convex  border,  and  the  examining  fmger  should  dis- 
cover and  break  into  every  pus-collection  of  appreciable  size.  Theo- 
retically nephrectomy  is  indicated,  since  the  kidney  is  often  riddled 
with  multiple  abscesses  ;  the  infection  is,  however,  frequently  bilateral. 
When  after  drainage  the  symptoms  do  not  improve  and  there  is  a 
free  discharge  of  pus  through  the  lumbar  wound,  a  secondary  ne- 
phrectomy may  be  performed  if  repeated  examinations  have  shown 
that  the  other  kidney  is  normal.  The  degenerated  fatty  capsule  is  in 
chronic  inflammations  often  adherent  to  the  kidney  capsule  proper, 
and  to  surrounding  organs  and  structures,  rendering  enucleation  of 
the  kidney  a  difficult  and  dangerous  procedure.  The  nephrectomy 
should  then  be  accomphshed  by  decortication,  the  kidney  being 
shelled  from  its  proper  capsule,  and  a  pedicle  being  formed  at  the 
expense  of  a  portion  of  its  substance  about  the  hilum. 

Suppurative  Nephritis. — Under  this  heading  are  classified 
renal  suppurations  in  which  the  agents  of  infection  enter  the  kid- 
neys through  its  vessels,  through  its  lymph-channels,  or  by  contiguity. 
Such  suppurations  are  seen  in  pyaemia,  in  endocarditis,  and  in  the 
acute  infectious  fevers,  as  the  result  of  extension  of  infection  from 
adjacent  tissues,  or  in  consequence  of  traumatism  or  exposure  to  cold. 

In  haematogenous  infections  the  condition  is  at  first  often  unilateral, 
though  embolic  infection  may  simultaneously  involve  both  kidneys. 
The  abscesses  are  generally  multiple  ;  single  large  abscesses  are  occa- 
sionally seen.  Haematogenous  abscesses  first  form  in  the  cortex  ;  from 
these  the  entire  gland  generally  becomes  infected.  The  abscesses  may 
coalesce,  and  in  some  cases  renal  disintegration  goes  so  far  that  nothing 
remains  but  a  sac  (the  capsule)  filled  with  pus.  In  non-haematogenous 
suppuration  the  process  may  commence  in  any  part  of  the  kidney,  ac- 
cording to  the  origin  of  infection.  The  abscesses  may  rupture  into  the 
pelvis  or  through  the  capsule,  with  the  production  of  perinephric  suppu- 
ration.   It  is  in  suppurative  nephritis  that  metastasis  most  often  occurs. 


e578 


GEXITO-UEIXAKY   DISEASES   AXD   SYPHILIS. 


When  the  kidney  infection  is  simply  an  expression  of  a  general 
pysemia  the  suppuration  is  rarely  extensive ;  small  abscesses  form 
about  the  glomeruli  and  the  smaller  vessels  of  the  cortex  of  both 
kidneys,  often  with  blocking  of  the  uriniferous  tubes.  The  renal 
substance  is  the  seat  of  a  parenchymatous  inflammation.     In  rare 

cases  of  long  duration,  amy- 
'^'      '^  loid  degeneration  may  occur. 

Symptoms.  —  Acute  hae- 
raatogenous  renal  infection 
is  often  inaugurated  by 
chill  and  high  fever ;  some- 
times patients  complain  of 
violent  pains  in  the  loin. 
This  may  be  associated  with 
tympany,  tenderness  and 
vomiting.  Tenderness  is 
most  marked  at  the  costo- 
vertebral angle,  and  may  be 
the  only  localizing  symp- 
tom. Not  infrequently  a 
marked  oliguria  (or  even 
anuria)  occurs.  Blood  and 
hyaline  casts  may  be  pres- 
ent m  the  urine. 

Fever  of  a  hectic  type 
develops  in  nearly  all  cases, 
and  chills  occur  irregularly. 
Violent  attacks  of  hiccough 
and  vomiting  are  sometimes 
noted  ;  these  are  probably 
ursemic.  There  are  generally  lumbar  pains,  severe  prostration,  and 
the  rapid  development  of  a  typhoid  state,  the  sensorium  becoming 
clouded,  and  the  patient  dying  with  symptoms  of  both  pyaemia  and 
uraemia.  Typical  uraemia  with  convulsions  has  been  noted  in  a  few  cases. 
The  urinary  changes  are  not  constant.  In  some  cases  there  are  no 
alterations  other  than  oliguria.  A  little  blood  and  a  few  hyaline  casts 
are  often  found  on  microscopic  examination.  Later  in  the  disease 
granular  casts  give  evidence  of  parenchymatous  degeneration.  Pyuria, 
especially  if  profuse,  indicates  that  an  abscess  has  been  evacuated  into 
the  pelvis  ;  this  may  be  followed  by  marked  amelioration  in  the  general 
condition.     In  rare  cases  pieces  of  renal  tissue  may  be  voided. 

Diagnosis. — Since  enlargement  of  the  kidney  is  usually  slight,  sup- 


Complete  destruction  of  kidney  by  an  abscess.  Small 
supernumerary  kidney  above.  (From  a  patient  in  the 
University  Hospital. ) 


SUPPUKATIVE   DISEASES   OF    THE    KIDNEY.  579 

purative  nephritis  will  not  ordinarily  be  confused  with  the  extrarenal 
suppuration.  The  course  of  suppurative  nephritis  is  too  acute  for 
neoplasms ;  hydronephrosis,  pyonephrosis,  and  perinephric  abscess 
generally  occasion  much  more  marked  enlargement.  The  careful 
examination  of  the  urine,  the  history  of  the  case,  and  exploration 
of  the  lower  urinary  tract  will  usually  lead  to  a  diagnosis.  Renal 
suppuration,  unless  well  drained,  causes  a  circulatory  leucocytosis. 

Treatment. — This  is  at  first  expectant  and  symptomatic.  The 
patient  is  kept  absolutely  at  rest,  and  careful  attention  is  paid  to  the 
constitutional  condition.  If  the  constitutional  symptoms  are  those  of 
profound  and  increasing  sepsis,  and  the  local  symptoms  are  unilateral, 
an  early  nephrectomy  may  be  performed  (Brewer).  It  is  often  the 
case  that  symptoms  pointing  to  the  renal  location  of  the  infection  are 
masked  until  the  condition  of  the  patient  will  not  admit  of  an  opera- 
tion. When  suppurative  nephritis  develops  in  pyaemia  it  is  a  local 
expression  of  the  general  condition,  to  which  treatment  is  mainly  directed. 

Perinephritis. — Perinephritis  is,  strictly  speaking,  an  inflamma- 
tion of  the  fibrous  capsule  ;  the  term,  as  commonly  used,  imphes  in- 
flammation of  the  fatty  capsule.  Inflammation  of  the  true  capsule 
occurs  in  nearly  all  renal  diseases.  It  is  frequently  sclerotic,  thick- 
ened, and  adherent  to  the  gland ;  it  may  suppurate  secondarily  to 
adjacent  renal  suppuration,  or  it  may  become  involved  in  tubercular 
and  malignant  processes. 

Beyond  the  evidences  of  the  renal  or  perirenal  disease  which 
causes  it,  true  perinephritis  presents  no  symptom  except  pain.  It 
seems  clearly  established  that  inflammation  of  the  true  kidney  capsule 
causes  more  pain  than  involvement  of  the  secreting  portion  of  the 
kidney. 

Inflammation  of  the  fatty  capsule  of  the  kidney  is  very  common, 
since  this  tissue  possesses  a  low  degree  of  power  of  resistance  to 
infection. 

Perinephritis  is  not  necessarily  suppurative.  After  a  long-lasting 
nephritis  it  sometimes  happens  that  the  capsule  of  the  kidney  is  con- 
verted into  a  dense  fibrous  investment,  the  fat  having  almost  entirely 
disappeared,  or  the  fatty  envelope  of  the  organ  may  be  greatly  thick- 
ened, showing  an  increase  of  both  adipose  and  fibrous  tissue.  This 
overgrowth  is  particularly  abundant  about  the  hilum,  and  much 
resembles  in  structure  lipomata  occurring  in  other  portions  of  the 
body. 

There  are  two  forms  of  perinephric  abscess :  the  primary,  in 
which  the  suppuration  arises  de  novo  in  the  fatty  capsule  ;  and  the 
secondary,  in  which  the  primary  focus  hes  elsewhere. 


580  GEISriTO-UEIKAEY   DISEASES   AND   SYPHILIS. 

The  primary  forms  of  perinephric  abscess  may  arise  in  several 
ways.  Traumatism  is  responsible  for  some  cases.  In  injuries  to  the 
lumbar  region  when  there  is  penetration,  laceration,  or  cutaneous 
abrasion,  pyogenic  micro-organisms  have  direct  access  to  the  tissues, 
and  infection  may  follow ;  but  there  have  been  cases  of  perinephric 
suppuration  following  traumatism  in  which  no  superficial  injuries 
occurred.  The  rare  instances  in  which  such  suppuration  has  fol- 
lowed severe  jarring  to  the  trunk  or  heavy  lifting  must  be  classed 
with  the  primary  cases.  Many  cases  have  been  attributed  to  colds. 
The  infection  must  be  explained  in  one  of  several  ways  :  it  may  have 
been  haematogenous,  the  traumatism  or  the  cold  having  rendered 
the  tissues  susceptible  to  the  circulatory  micro-organisms ;  or  the 
traumatism  may  have  excited  to  activity  a  latent  disease.  There  may 
also  be  a  perinephritis  due  to  actinomycosis. 

The  secondary  perinephric  suppurations  arise  from  many  causes. 
From  the  kidney  secondary  infection  is  common.  In  any  case  of 
suppurative  nephritis,  pyelonephritis,  pyonephrosis,  hydronephrosis, 
pyelitis  (especially  associated  with  calculus),  ureteritis,  tubercular, 
malignant,  or  cystic  disease,  a  perinephric  abscess  may  form.  The 
infection  may  be  due  either  to  the  rupture  of  an  area  of  renal  suppu- 
ration into  the  perinephric  tissue,  or  to  extension  through  the  true 
capsule  without  discoverable  opening.  The  infection  may  reach 
the  fatty  capsule  from  its  periphery.  Thus,  perityphlitis  and  appen- 
dicitis, parametritis  and  parovaritis,  malignant  disease  of  the  colon, 
abscess  of  the  spleen,  gall-bladder,  or  liver,  subphrenic  abscess,  psoas 
abscess,  or  any  bone  suppuration,  and  in  rare  cases  abscess  of  the 
lung  or  pleura,  may  be  the  primary  focus  of  suppuration. 

In  other  cases  infection  may  reach  the  fatty  tissues  by  the  blood- 
or  lymph-channels.  In  pysemia  or  internal  suppuration,  in  puerperal 
fever,  or  after  operations  on  the  prostate,  bladder,  testicles,  rectum,  or 
ischiorectal  spaces,  such  an  infection  may  occur.  Finally,  there  are 
rare  instances  of  perinephric  suppuration  entirely  without  obvious 
cause,  in  which  an  infection  by  micro-organisms  from  the  colon  may 
be  possible.  The  condition  is  most  common  in  men  (of  one  hundred 
and  thirty-eight  cases  collected  by  Nieden  ninety-seven  were  in  men). 
Most  of  the  cases  have  occurred  in  middle  hfe,  but  there  have  been 
cases  in  children  (one  at  five  weeks)  and  in  persons  over  sixty  years. 
The  right  side  has  been  found  more  often  affected,  and  in  at  least  two 
instances  the  condition  was  bilateral.  The  abscesses  may  be  large 
or  small,  single  or  multiple.  The  latter  condition  is  most  often  seen 
in  cases  where  infection  has  proceeded  from  the  kidney.  The  pus 
may  spread  from  the  fatty  capsule  and  infiltrate  the  loose  retroperi- 


SUPPUKATIVE   DISEASES   OF   THE   KIDNEY.  581 

toneal  tissue  ;  in  other  cases  it  is  walled  in  by  a  strong  fibrous  capsule. 
The  perinephric  lipomatous  investment  is  more  or  less  necrotic,  and 
bleeding  is  not  uncommon  in  the  infected  area.  The  pus  is  usually- 
bland  and  odorless ;  it  may,  however,  be  fetid  (intestinal  infection  ?), 
or  urinous.  According  to  its  origin  the  pus  may  contain  renal  tissue, 
concretions,  parasites,  or  shreds  of  neoplasm.  The  kidney-substance 
often  becomes  secondarily  involved,  and  amyloid  degeneration  may 
ensue.     Metastasis  to  distant  organs  is  rare. 

The  main  portion  of  the  abscess  is  usually  placed  directly  behind 
the  kidney,  but  the  pus  may  burrow  in  various  directions,  and  this 
tendency  is  of  great  clinical  importance.  It  may  descend  into  the 
pelvis  behind  the  peritoneum,  opening  into  the  rectum,  vagina,  urethra, 
or  bladder  (in  about  four  per  cent,  of  recorded  cases).  It  may  pass 
down  within  the  sheath  of  the  psoas  muscle  and  point  below  Pou- 
part's  ligament,  may  follow  the  iliac  vessels  and  point  in  the  femoral 
region,  or  may  pass  out  through  the  sacro-sciatic  foramen  and  point 
in  the  gluteal  region.  Rupture  into  the  ureter  or  the  kidney  is  pos- 
sible. In  a  few  cases  the  abscess  has  discharged  into  the  colon  (of 
six  cases,  four  recovered),  duodenum,  or  stomach ;  the  liver  may  be 
secondarily  infected.  Rupture  into  the  peritoneal  cavity  is  rare,  as 
the  peritoneum  becomes  thick  and  fibrous  as  a  result  of  inflamma- 
tion. The  upward  pressure  of  an  extensive  perinephric  abscess  may 
be  sufficient  to  cause  distressing  dyspnoea. 

Perhaps  the  most  frequent  direction  of  pointing,  with  the  excep- 
tion of  those  abscesses  which  open  in  the  lumbar  region,  is  towards 
the  pleural  cavity.  Senator  long  ago  called  attention  to  the  exist- 
ence of  a  serous  pleurisy  which  often  complicates  perinephritis,  even 
though  the  abscess  has  not  directly  involved  the  pleura.  It  has  been 
shown  that  there  is  a  triangular  defect  in  the  diaphragm  just  behind 
the  upper  portion  of  the  kidney :  hence  there  is  httle  to  prevent  the 
extension  of  pus  upward  when  the  perinephric  tissues  suppurate. 
After  rupture  through  the  diaphragm  the  pus  may  infiltrate  the  retro- 
pleural  tissue,  penetrate  the  pleural  cavity,  causing  empyema,  or 
rupture  into  the  lung,  giving  rise  to  pulmonary  abscess.  In  some 
cases  profuse  purulent  expectoration  or  the  symptoms  of  suppurative 
pleuritis  first  attract  attention  to  the  perinephric  suppuration,  though, 
unless  it  is  remembered  that  perinephritis  may  be  a  causative  factor, 
the  etiology  of  the  pulmonary  abscess  or  the  empyema  may  remain 
unsuspected.  In  Fisher's  series  of  ninety-four  cases  the  pleura  was 
affected  in  twenty-four  per  cent.,  the  lungs  in  twenty  per  cent.,  and 
the  pericardium  in  six  per  cent. 

Symptoms. — The  cardinal  symptoms  of  perinephritis  are  tumor. 


582  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

pain,  tenderness,  and  fever.  The  local  symptoms  depend  upon  the 
formation  of  pus  and  the  direction  of  its  extension.  In  the  cases 
which  are  secondary  to  inflammation  of  the  appendix,  the  uterus  or 
■its  adnexa,  the  gall-bladder,  etc.,  the  symptoms  of  perinephritis  are 
masked  by  those  of  the  original  disease.  This  is  also  true  of  sup- 
puration secondary  to  infection  of  the  uro-genital  tract  or  which  occurs 
in  the  course  of  a  general  pysemia. 

The  symptoms  are  clearly  marked  in  cases  following  traumatism 
or  cold  or  in  those  of  haematogenous  origin  unassociated  with  general 
pyaemia.     Pain,  chill,  and  fever  are  generally  the  early  phenomena. 

The  pain  is  at  first  confined  to  the  loin  and  aggravated  by  press- 
ure ;  soon  any  motion  of  the  trunk  or  leg  of  the  affected  side  greatly 
increases  it.  The  patient  lies  on  his  back,  with  a  lateral  curvature  the 
concavity  of  which  is  towards  the  side  involved ;  the  thigh  is  ad- 
ducted  and  flexed.  At  times  severe  pains  may  radiate  into  the  geni- 
talia, around  the  abdomen,  or  into  the  thigh  ;  this  is  due  to  pressure 
upon  the  nerve-trunks.  Even  in  the  feverless  walking  cases  the  mus- 
cles attempt  to  protect  the  inflamed  region  ;  the  thigh  is  adducted,  the 
body  is  bent  forward,  and  the  trunk  is  fixed,  usually  with  a  lumbar 
flexure  towards  the  inflammatory  focus  ;  the  patient  Hmps.  In  a  few 
cases  partial  anaesthesia  and  paresis  have  been  noted.  Since  the 
third  and  fourth  lumbar  nerves  supply  the  muscles  which  flex  the 
thigh,  this  symptom  of  flexion  is  most  prominent  where  the  abscess 
Kes  directly  over  them, — that  is,  about  the  lower  third  of  the  kidney. 
In  some  cases  the  thigh  is  fixed  in  flexion ;  in  other  cases  any 
motion  except  extension  may  be  performed  painlessly. 

The  fever  may  be  high  or  moderate  ;  it  is  usually  markedly  inter- 
mittent or  even  remittent,  and  often  presents  the  distinct  hectic  type. 
Chills  and  profuse  perspiration  are  common.  The  blood  generally 
shows  leucocytosis,  except  when  the  condition  is  secondary  to  bone 
tuberculosis.  The  gastro-intestinal  tract  is  deranged,  there  are  ano- 
rexia, vomiting,  sometimes  tympany,  and  these  disturbances  may  be 
much  aggravated  by  the  pressure  of  the  abscess  upon  the  colon,  with 
the  production  of  obstruction  and  con:  _  quent  stercoraemia. 

The  local  symptoms  develop  early.  There  is  a  tender  tumor  in 
the  loin,  which  may  be  indistinctly  fluctuating  and  irregular  in  out- 
fine.  The  abscess  fies  under  the  colon,  and  therefore  usually  does 
not  produce  an  area  of  dulness  on  anterior  percussion,  but  flatness  is 
marked  in  the  lumbar  region. 

The  loin  is  usually  swollen ;  this  swelling  may  be  so  slight  that 
careful  measurements  are  necessary  to  demonstrate  it,  or  it  may  be 
so  distinct  that  the  lumbar  region  protrudes.     This  tumor  does  not 


SUPPURATIVE   DISEASES   OF   THE   KIDJS^EY.  583 

move  with  respiration.  When  external  pointing  is  about  to  take 
place,  the  skin  over  the  loin  becomes  red  and  waxy,  and  distinct 
cedema  develops ;  the  abscess  usually  opens  in  or  near  Petit's 
triangle. 

Supradiaphragmatic  symptoms  often  develop.  Independent  of 
perforation  into  the  pleura,  severe  pleurisy  may  occur,  presenting  the 
recognized  symptoms  of  that  condition.  In  nearly  all  cases  there  is 
restricted  abdominal  breathing,  and  hence  some  dyspnoea  and  an  irri- 
table cough.  Apart  from  diaphragmatic  rigidity,  extreme  dyspnoea 
may  be  produced  by  direct  pressure  of  a  large  abscess. 

In  the  acute  cases  the  general  strength  of  the  patient  is  quickly 
and  markedly  reduced,  prostration  is  extreme,  and,  unless  there  is 
natural  or  artificial  evacuation,  the  patient  becomes  profoundly  septi- 
csemic,  or  even  may  succumb  to  a  general  pygemia.  The  tubercular 
cases,  however,  and  some  of  the  infective  cases,  run  a  mild  chronic 
course,  in  which  the  local  phenomena  largely  predominate. 

When  the  abscess  forms  visceral  adhesions,  or  shows  a  tendency 
towards  pointing  externally,  additional  symptoms  usually  appear, 
though  evacuation  may  be  accomphshed  almost  without  symptoms. 
Opening  into  the  loin  is  heralded  by  the  well-known  local  signs  of 
abscess-formation.  Evacuation  into  the  intestines  is  preceded  and  ac- 
companied by  colicky  or  continuous  pains  and  a  desire  to  defecate ; 
when  such  symptoms  arise,  pus  should  be  sought  for  in  the  evacua- 
tion. Symptoms  of  acute  peritonitis  may  appear;  these  are  usually 
reflex,  or  indicate  intestinal  implication  rather  than  peritonitis.  Rup- 
ture into  the  kidney  or  the  urethra  is  accompanied  by  mild  or  severe 
renal  cohcs  with  frequent  urination;  the  same  pains,  together  with 
vesical  irritability,  may  be  present  in  case  of  rupture  into  the  bladder, 
though  this  may  take  place  without  producing  any  symptoms.  The 
downward  and  forward  extension  of  the  abscess  is  indicated  by  the 
increasing  area  of  tenderness  and  the  detection  by  palpation  of  in- 
flammatory thickening  of  the  tissues. 

Rupture  into  the  pleura  is  accompanied  by  severe  cough,  dyspnoea, 
and  the  physical  signs  of  empyema ;  later  there  forms  a  lung  abscess, 
or  a  pneumo-pyothorax  ;  such  an  abscess  may  be  evacuated  through 
the  bronchus. 

In  most  cases  immediately  following  rupture  of  the  abscess  there 
is  marked  amehoration  of  general  symptoms,  and  the  size  of  the 
tumor  is  decreased,  but  this  may  not  be  demonstrable.  When  fistulce 
have  formed  they  will  discharge  regularly  and  almost  continuously, 
but  not  unfrequently  the  tracts  become  blocked  ;  this  is  followed  by 
prompt  exaggeration  of  both  the  general  symptoms  and  the  local  signs. 


584  GENITO-UKINAKY   DISEASES    AND   SYPHILIS. 

Diagnosis. — Perinephric  abscess  may  be  confused  with — (a)  non- 
inflammatory conditions  of  other  tissues  ;  (6)  inflammatory  conditions 
of  other  tissues ;  (c)  neoplasms  of  the  kidneys  or  adjacent  tissues ; 
(d)  inflammatory  conditions  of  the  kidneys. 

Of  the  non-inflammatory  conditions,  lumbago,  lumbar  or  renal 
neuralgia,  renal  colic  and  faecal  impaction,  are  those  most  likely  to  be 
mistaken  for  perinephric  abscess.  In  lumbago  the  pains  are  gener- 
ally bilateral,  do  not  radiate  into  the  thighs,  but  along  the  course  of 
the  sciatic  nerve,  and  there  is  more  tenderness  over  the  bony  parts 
than  over  the  loin.  The  pain  in  neuralgia  is  often  intermittent,  and 
is  of  a  peculiar  sharp  quality  which  is  not  felt  in  perinephritis.  In 
renal  calculi  there  are  vesical  symptoms  and  retraction  of  the  testicle, 
followed  by  blood  and  possibly  stone  fragments  in  the  urine.  Faecal 
impaction  must  be  differentiated  by  the  history  and  by  physical  ex- 
amination. 

Certain  of  the  infectious  diseases  may  in  their  early  stages  simu- 
late perinephritis:  thus,  influenza,  small-pox,  and  cerebro-spinal 
fever  may  with  their  severe  loin-pains  and  fever  cause  confusion  until 
they  have  evolved  their  other  characteristic  signs.  Perinephritis 
may  also  simulate  typhoid  fever,  but  here,  as  in  the  non-inflamma- 
tory conditions,  there  would  be  no  leucocytosis  such  as  accompanies 
perinephric  abscess.  It  is  an  occasional  complication  of  typhoid 
fever. 

Of  the  inflammatory  conditions  of  other  tissues  which  may  be  con- 
founded  with  perinephritis,  appendicitis,  parametritis,  and  parovaritis 
are  the  most  common,  with  abscess  of  the  gall-bladder,  liver,  or 
spleen  as  rare  causes  of  confusion. 

The  pain  in  appendicitis  generally  begins  as  an  intestinal  colic,  and 
later  radiates  through  the  abdomen  or  towards  the  umbilicus  rather 
than  into  the  genitalia  or  down  the  thigh.  The  dulness  is  often  in 
front  of  the  colon,  and  more  marked  anteriorly  than  posteriorly,  and 
the  peritoneal  symptoms  are  more  pronounced.  Moreover,  the  point 
of  greatest  tenderness  does  not  coincide  in  the  two  affections.  These 
elements  of  difference,  with  the  history,  will  usually  determine  the 
diagnosis.  Rectal  exploration  should  also  be  made,  and  the  urine 
should  be  carefully  examined  for  pus. 

Parametritis  and  parovaritis  can  generally  be  differentiated  by  the 
history  and  by  vaginal  and  rectal  examinations. 

Visceral  abscesses  must  be  excluded  by  the  history  and  by  physical 
examination. 

Coxalgia  and  spinal  tuberculosis  may  be  closely  simulated  by 
perinephric  abscess.     The  position  of  the  leg  may  be  the  same  as 


SUPPUEATIVE    DISEASES   OF   THE    KIDNEY.  585 

in  coxalgia,  but  the  other  joint-symptoms  are  not  present.  Spinal 
tuberculosis  causes  a  marked  rigidity  of  the  vertebral  column,  with 
tenderness  over  certain  points,  pain  on  concussion,  with  relief  of  pain 
on  extension  of  the  spine,  and  angular  deformity ;  these  symptoms 
are  absent  in  perinephric  abscess.  Moreover,  there  is  no  leucocy- 
tosis  in  bone  tuberculosis  unassociated  with  mixed  infection. 

Neoplasms  of  the  kidney  or  adjacent  tissues  are  sometimes  very 
difficult  to  exclude,  since  the  swelling  of  a  perinephric  abscess  does 
not  always  fluctuate.  The  age  of  the  patient  might  suggest  the  prob- 
ability of  renal  neoplasm ;  fever  and  flexion  of  the  leg  would  almost 
positively  point  to  abscess.  In  doubtful  cases  a  careful  examinalion 
under  complete  narcosis  will  often  be  necessary  before  deciding  the 
question.  The  examination  of  the  urine  sometimes  furnishes  evi- 
dence of  perinephritis,  though,  unless  the  secreting  substance  or  the 
pelvis  of  the  kidney  is  inflamed,  the  examination  will  be  negative. 
Rapidly  growing  sarcomata  often  cause  a  decided  leucocytosis,  while 
a  mild  leucocytosis  may  be  present  in  cases  of  cancer ;  thus  this  sign 
of  abscess  may  be  misleading.  In  doubtful  cases  an  exploratory 
puncture  is  justifiable,  since  a  diagnosis  can  usually  be  made  from 
the  material  aspirated. 

Tumors  of  the  liver  or  gall-bladder  on  the  one  side,  or  of  the  spleen 
on  the  other,  may  be  eliminated  by  the  distention  of  the  stomach  and 
colon  with  air,  whereby  the  percussion  flatness  of  hepatic  and  splenic 
growths  would  be  exaggerated,  that  of  a  perinephric  abscess  dimin- 
ished. Ovarian  cysts  can  usually  be  excluded  by  vaginal  and  rectal 
examination  and  by  the  history. 

Of  the  inflammatory  conditions  of  the  kidney  which  may  be  mis- 
taken for  perinephric  abscess,  pyonephrosis,  pyelitis,  and  suppurative 
nephritis  are  the  most  frequent.  The  differential  diagnosis  is  often 
very  difficult,  but,  as  the  treatment  of  all  is  nearly  the  same,  the 
difficulties  are  not  discouraging.  The  tumor  of  hydronephrosis  or 
pyonephrosis  resulting  from  a  blocking  of  the  ureter  is  of  more  sud- 
den formation  than  an  abscess ;  there  is  not  the  marked  flexion  of 
the  thigh,  the  pain  is  more  paroxysmal,  and  there  is  in  hydrone- 
phrosis no  fever.  Examination  of  the  urine  is  in  such  cases  most 
helpful.  Pyelitis  and  suppurative  nephritis  do  not  occasion  swelhng, 
severe  pain,  or  flexion  of  the  thigh.  In  any  case  where  there  are 
pyuria  and  the  signs  of  perinephric  abscess,  it  will  be  important  to 
know  whether  the  pus  comes  from  the  urinary  tract  or  from  the 
abscess.  In  such  cases  methyl-blue  may  be  injected  into  the  abscess, 
and,  by  the  use  of  the  catheter  or  the  cystoscope,  the  time  of  the 
advent  of   the  coloring-matter  from  the  ureter  may  be  noted.     In 


586  GENITO-ITEINAPvY   DISEASES   AND   SYPHILIS. 

•case  the  abscess  (or  cyst  or  tumor)  communicates  with  the  renal  pelvis 
or  the  ureter,  this  should  occur  within  ten  minutes. 

The  knowledge  of  leucocytosis  in  the  various  renal  inflammations 
has  not  yet  been  so  formulated  as  to  be  of  clinical  service.  Careful 
repeated  examinations  of  the  urine  and  the  history  of  the  case  are 
the  most  important  elements  in  differentiating  perinephric  abscesses 
from  the  renal  infections. 

Prognosis. — This  is  dependent  upon  the  cause  of  the  perinephritis. 
When  the  perinephric  inflammation  is  secondary  to  infection  of  the 
kidney  the  prognosis  must  be  guarded.  When  it  follows  contusion 
of  the  kidney  the  prognosis  is  extremely  favorable  if  the  condition  is 
recognized  and  promptly  treated.  Poland's  statistics  are  instructive 
in  relation  to  the  value  of  early  operation.  Of  eight  cases  treated 
expectantly  six  died.     Of  twenty  cases  treated  by  operation  one  died. 

The  course  of  primary  perinephritis  is  usuafly  acute,  the  symp- 
toms are  severe,  and  the  inflammation  quickly  terminates  in  death  or 
evacuation  of  the  abscess.  Ih  a  few  cases  the  abscess  has  become 
encysted,  with  complete  recovery,  and  the  pathology  of  abscesses  in 
other  parts  of  the  body  shows  the  possibility  of  such  a  termination. 

In  case  of  pointing  the  subsequent  history  of  the  case  depends 
upon  the  site  of  evacuation.  Most  favorable,  of  course,  is  lumbar  or 
iliac  evacuation,  next  is  rupture  into  the  colon,  then  rupture  into  the 
urinary  tract,  and  most  unfavorable  is  rupture  through  the  diaphragm. 
In  the  secondary  cases  the  duration  and  prognosis  are  obviously  in- 
fluenced by  the  primary  conditions. 

Treatment. — When  the  diagnosis  of  perinephric  abscess  is  fairly 
■established  there  can  be  no  reason  for  delay  in  surgical  intervention. 
Palliative  treatment  is  indicated  only  during  the  time  the  surgeon  is 
determining  whether  or  not  pus  is  present  in  the  perinephric  region. 
Before  the  formation  of  a  distinct  tumor  it  may  be  quite  impossible 
to  distinguish  perinephritis  from  any  of  the  forms  of  kidney  infection. 
During  this  period  the  treatment  appropriate  to  suppurative  renal 
disease  is  indicated.  This  imphes  rest  in  bed,  counter-irritation  ap- 
phed  to  the  lumbar  region,  the  rehef  of  pain  by  injections  of  mor- 
phine, the  administration  of  mild  antiseptics,  diuretics,  and  liquid 
diet,  preferably  milk,  and  regulation  of  the  bowels  by  salines  or  by 
enemata. 

When  incision  is  practised,  the  opening  should  be  in  the  lumbar 
region,  and  should  be  sufficiently  large  to  allow  of  exploration  of 
the  kidney  and  its  pelvis.  It  is  best  to  use  the  finger  instead  of  the 
knife  to  open  up  the  abscess-cavity  and  break  down  septa.  The  ad- 
mixture" of  urine  with  the  pus  indicates  that  there  js  an  opening  into 


SUPPUEATIYE    DISEASES    OF    THE    KIDNEY.  587 

■the  kidney  pelvis,  and  suggests  exploration  of  this  cavity  and  of  the 
ureter  for  the  purpose  of  removing  calculi  or  relieving  obstruction. 
Frequently  the  pus  has  a  fsecal  odor,  suggesting  a  communication 
with  the  bovirel.  This  odor  does  not,  however,  indicate  the  formation 
of  an  intestinal  fistula,  but  is  probably  due  to  the  close  proximity  of 
the  focus  of  suppuration  to  the  large  intestine,  certain  saprophytic 
micro-organisms  contained  in  the  colon  apparently  having  the  power 
to  pass  through  its  walls.  When  the  abscess  has  burrowed  widely 
its  accessory  cavities  should  be  opened  and  drained ;  heahng  of  these 
may  be  confidently  expected  after  drainage  of  the  centre  of  infection. 
In  cases  of  long  duration  and  where  the  abscess  is  of  large  size,  the 
pressure  may  have  caused  marked  atrophy  of  the  kidney,  or  this 
organ  may  be  so  extensively  infiltrated  with  pus  that  nephrectomy  is 
indicated.  In  such  cases  it  is  safest  to  perform  two  operations,  let- 
ting the  patient  recover  from  the  constitutional  effects  of  suppuration 
before  submitting  him  to  the  shock  and  strain  of  a  nephrectomy. 

When  the  abscess  has  already  opened,  into  a  bronchus  or  the  colon, 
for  instance,  it  is  possible  that  spontaneous  cure  may  result.  Sur- 
gical intervention  may  then  be  delayed,  provided  the  patient's  general 
condition  is  satisfactory  and  the  quantity  of  pus  discharged  is  dimin- 
ishing. Should  hectic,  emaciation,  and  loss  of  strength  show  deficient 
drainage  and  ptomaine  absorption,  the  centre  of  infection  should  be 
drained  directly.  The  after-treatment  of  the  incision  made  for  drain- 
age is  important,  since  fistulse  are  liable  to  persist,  especially  in  cases 
of  long-standing  suppuration  and  in  those  complicated  by  pyelo- 
nephritis. Drainage  should  be  thorough,  and  is  best  secured  by 
gauze  packing,  which  is  so  renewed  at  subsequent  dressings  that  the 
wound  heals  from  the  bottom. 

Pyelo-Paranephric  Cyst. — A  cystic  tumor  within  the  paranephric 
tissue  connecting  with  a  fistula  of  the  renal  pelvis  has  been  described 
by  Gallaudet.  It  may  be  due  to  a  simultaneous  rupture  of  the  renal 
pelvis  and  the  formation  of  a  paranephric  haematoma.  The  blood 
finally  becoming  absorbed  leaves  a  connective-tissue  capsule  formed  by 
perinephric  tissue,  the  cavity  of  which  communicates  with  the  pelvis 
of  the  kidney.  It  may  occur  as  the  result  of  traumatism  or  of  ulcera- 
tion of  the  renal  pelvis  with  urinary  extravasation.  Removal  of  the 
mass  and  closure  of  the  fistula  would  constitute  the  treatment. 

Renal  Infarct. — The  first  indication  of  this  in  a  patient  with  valvu- 
lar cardiac  disease  may  be  sudden  vomiting.  There  may  be  either  reten- 
tion, suppression  or  incontinence  of  urine,  later  followed  by  polyuria. 
Haematuria  is  rare,  albuminuria  develops  rapidly,  but  is  transient. 
The  renal  pain  and  tenderness  are  increased  by  lying  on  the  sound 


588  GENITO-UKINAEY    DISEASES   AND   SYPHILIS 

side  and  the  sensibility  of  the  ileo-hypogastric  nerve  is  exaggerated. 
(Schmidt.) 

Phlebitis  of  the  Renal  and  Perirenal  Veins  is  a  rare  condition, 
which  may  arise  as  a  result  of  pyasmia,  or  may  be  a  beginning  of 
nephric  or  perinephric  abscess.  It  presents  the  symptoms,  both  con- 
stitutional and  local,  of  severe  acute  inflammation  in  or  about  the  kid- 
ney with  extreme  tenderness,  rigidity,  pain,  oedema  of  the  surrounding 
soft  parts,  chills,  fever  and  sweats  of  a  hectic  type  going  on  to  the 
production  of  pronounced  cachexia.  The  urinary  symptoms  may  be 
negative,  or,  if  abscesses  have  been  formed,  there  will  be  pus  and  blood 
in  the  urine.  Suppression  may  occur.  The  extreme  rigidity  and  ten- 
derness which  call  attention  to  the  kidney  may  preclude  palpation  of 
the  organ.  The  diagnosis  is  made  largely  by  exclusion  and  upon  ex- 
ploration of  the  kidney.     The  few  cases  seen  have  been  unilateral. 


CHAPTER   XVII. 

HYDRONEPHKOSIS. RENAL    TUBERCULOSIS. RENAL   FISTULA. PARASITES  AND 

TUMORS. 

HYDRONEPHROSIS. 

This  is  a  condition  characterized  by  distention  of  the  kidney  pelvis 
with  fluid,  usually  urine.  -Morris,  however,  has  recorded  a  case  in 
which  the  fluid  was  composed  wholly  of  water  and  sodium  chloride, 
without  a  trace  of  urea  or  albumen  or  any  other  characteristic  of 
urine.  It  is  associated  with  pressure,  atrophy  of  the  kidney,  and  in- 
terstitial nephritis,  the  gland  and  its  pelvis  becoming  converted  into 
a  fibrous,  thick-walled  sac,  in  which  the  fluid  is  contained.  The  cause 
of  hydronephrosis  is  obstruction  to  the  flow  of  urine  through  any  por- 
tion of  the  urinary  tract ;  this  results  in  distention  and  paresis  of  the 
pelvic  and  ureteral  muscles. 

Hydronephrosis  may  be  congenital  or  acquired,  permanent  or 
intermittent,  unilateral  or  bilateral,  partial  or  total.  In  permanent 
hydronephrosis  the  distention  is  continuous  ;  in  the  intermittent  form 
of  the  affection  there  are  periods  during  which  the  obstruction  is  re- 
lieved and  the  retained  fluid  escapes,  usually  into  the  bladder.  Partial 
hydronephrosis  is  caused  by  blocking  of  one  or  more  caHces  ;  this  may 
be  due  to  stone  or  to  cicatricial  contraction.  Total  hydronephrosis 
results  from  obstruction  of  the  pelvic  orifice  or  of  the  tract  below ; 
stone  is  the  common  cause,  though  blood-clots,  masses  of  coherent 
pus,  fragments  of  tissue,  or  parasites  exceptionally  may  occasion  ob- 
struction. The  ureters  may  be  blocked  congenitally,  or  as  the  result 
of  external  pressure,  traumatism*  inflammation,  or  lodgement  of  a 
solid  or  semi-solid  substance.  They  may  be  strictured  in  any  part  of 
their  course. 

Congenital  hydronephrosis  may  be  unilateral  or  bilateral. 
Among  the  causes  are  imperforate  urethra  or  ureter.  Malformation, 
folds  or  duplicatures  of  the  mucous  membrane  at  the  vesical  orifice, 
congenital  tumors  of  the  bladder,  ureters,  or  neighboring  organs,  float- 
ing kidney,  and  obstruction  by  the  blood-vessels  of  the  kidney,  are 
occasional  causes. 

Congenital  stricture  usually  entirely  obliterates  the  ureters.  There 
may  be  a  narrowing  at  the  uretero-pelvic  junction,  or  even  a  valvular 

589 


590  GENITO-URINARY   DISEASES   AND   SYPHILIS 

formation  here.  Later  in  life  there  is  sometimes  an  obstruction  at 
this  point,  caused  by  the  inflamed  mucous  membrane,  which  Kiister 
states  shdes  downward  from  its  attachment,  thus  creating  a  valve. 
The  ureters  sometimes  enter  obliquely  or  at  an  angle  unfavorable  to 
free  drainage.  This  conformation  may  be  congenital  or  may  be  due 
to  gradual  dilatatioi;!  of  the  pelvis.  Or  the  ureter  may  enter  the 
pelvis  at  a  point  higher  than  normal,  thus  encouraging  retention  of 
urine  and  distention.  Tension  exerted  by  an  unevenly  distended 
capsule  may  so  draw  upon  the  ureteral  orifice  as  to  alter  it  in  form 
and  interfere  with  the  flow  of  urine. 

If  the  disease  is  bilateral  it  is  rapidly  fatal.  Hydronephrosis  may 
be  present  at  birth  or  may  appear  subsequently  because  of  congenital 
deformity.  When  the  disease  is  congenital  the  dilatation  usually 
attains  proportionally  a  much  greater  size  than  when  it  is  acquired. 
Even  though  the  congenital  obstruction  is  caused  by  an  impervious 
ureter,  the  kidney  does  not  atrophy,  since  during  intra-uterine  life  it 
secretes  much  more  slowly  than  after  birth,  and  consequently  intra- 
renal  pressure  is  not  developed  with  sufficient  rapidity  to  arrest  secre- 
tion before  the  delicate  pelvic  and  ureteral  tissues  have  become  relaxed 
and  overstretched. 

The  treatment  is  the  same  as  that  of  acquired  hydronephrosis. 
When  there  is  reason  to  believe  that  the  obstruction  is  caused  by 
movable  kidney  or  impacted  calculus  it  is  possible  that  manipulation 
through  the  abdominal  walls,  aided  by  lumbar  aspiration,  may  re- 
lieve symptoms.  When  the  hydronephrosis  is  due  to  stricture  or  to 
valve-formation,  lumbar  incision  followed  by  an  attempt  to  remove 
the  obstruction  is  justifiable.  Should  the  obstruction  be  irremedi- 
able, permanent  drainage  of  the  pelvis,  or,  if  the  disease  is  unilateral, 
nephrectomy,  is  indicated. 

Acquired  hydronephrosis  is  most  frequent  in  women,  probably 
because  they  are  so  commonly  subject  to  pelvic  disease  and  floating 
kidneys.  It  may  be  due  to  pelvic  tumors,  particularly  those  of  a  can- 
cerous nature,  displacements  of  the  womb,  pelvic  inflammations,  vesi- 
cal neoplasms,  traumatism,  unnatural  mobility  of  the  kidney,  calculi, 
stricture  of  the  urethra,  enlarged  prostate,  genito-urinary  tuberculosis, 
and  irritable  bladder.  This  last  condition  is  operative  because  the 
frequent  act  of  micturition  has  a  tendency  constantly  to  close  the 
vesico-ureteral  outlets,  producing  backward  pressure  upon  the  pelvis 
of  the  kidney. 

Of  six  hundred  and  sixty-five  cases  tabulated  by  Newman,  stric- 
ture of  the  urethra  and  enlarged  prostate  and  hypertrophy  of  the 
bladder  were  found  to  be  the  cause  in  one  hundred  and  ninety-five 


HYDRONEPHROSIS.  59I 

bilateral  and  thirty-nine  unilateral  cases  of  hydronephrosis.  Next 
in  order  of  frequency  come  tumors  of  the  pelvic  organs,  causing  com- 
pression of  the  ureters.  From  this  alone  there  were  one  hundred  and 
forty-three  bilateral  and  forty-one  unilateral  cases.  Renal  calculus 
produces  unilateral  hydronephrosis  more  often  than  any  other  of  the 
causes  noted,  fifty-one  cases  being  due  to  that  alone  ;  it  was  found  to 
be  the  cause  of  only  seventeen  cases  of  bilateral  dilatation. 

In  a  certain  number  of  cases  observed  at  post-mortem  examina- 
tions no  causes  have  been  discovered.  These  may  have  been  due  to 
the  acute  angle  of  entrance  of  the  ureter  into  the  pelvis  or  to  undue 
irritability  of  the  ureter.  It  is  possible  that  the  retention  of  urine  is 
under  such  circumstances  owing  to  paresis  of  the  detrusor  muscles,  an 
expression  of  neurosis  corresponding  to  the  vesical  retention  of  urine 
observed,  after  traumatic,  degenerative,  or  functional  disturbances  of 
the  spinal  cord. 

The  effect  of  hydronephrosis  upon  the  kidney  structure  depends 
upon  the  completeness  and  the  duration  of  the  obstruction.  Excep- 
tionally the  dilatation  is  confined  solely  to  the  pelvis.  Usually  the 
kidney  is  involved  sooner  or  later,  forming,  with  the  pelvis,  a  rounded, 
irregularly  nodulated  tumor,  varying  greatly  in  size.  Even  in  enor- 
mously dilated  kidneys  there  may  be  some  remnants  of  secreting 
substance.  As  a  rule,  the  walls  of  the  cyst  are  made  up  of  fibrous 
tissue. 

Griffiths  has  carefully  studied  the  histological  changes  produced 
by  hydronephrosis.  There  are  two  distinct  processes,  one  the  result 
of  pressure  hmited  to  the  tissue  pressed  upon  ;  the  other  a  degenera- 
tion identical  with  that  seen  in  chronic  interstitial  nephritis,  due  in 
part  to  the  distention  of  the  pelvis,  which  by  compressing  and  stretch- 
ing the  renal  vessels  as  they  pass  into  the  kidney  interferes  with  the 
nutrition  of  the  whole  organ.  Distention  of  the  pelvis  takes  place 
mainly  in  a  forward  direction,  pushing  the  renal  vessels  which  lie  in 
front,  and  thus  stretching  and  flattening  them.  In  the  later  stages  of 
hydronephrosis  there  is  thickening  of  the  intima,  and  even  of  the 
media,  with  the  formation  of  fibrous  connective  tissue,  thus  contrib- 
uting to  further  diminution  in  the  calibre  of  the  channels  which 
supply  the  kidneys  with  blood.  Occasionally  thrombi  develop  in 
these  vessels.  The  cortical  substance  of  the  kidney  is  the  slowest  to 
disappear. 

Finally  the  whole  secreting  substance  is  converted  into  connective 
tissue.  The  perinephric  fat  is  infiltrated  and  adherent.  The  dilated 
larger  excretory  tubes  persist  for  some  time  ;  at  last  even  traces  of 
these  disappear,  the  hydronephrotic  kidney  forming  a  huge  sac,  some- 


592 


GEJSriTO-URINAKY   DISEASES   AND   SYPHILIS. 


times  incrusted  with  urinary  salts.  The  participation  of  the  ureter 
depends  upon  the  seat  of  obstruction.  This  sac  contains  acid  urine, 
often  hyaline  casts  and  blood.  The  salts  are  sometimes  precipitated, 
forming  a  thick,  semi-liquid,  brownish  mass.  The  sound  kidney 
becomes  hypertrophied.  Symptoms  are  at  times  completely  absent, 
and,  provided  the  other  kidney  undergoes  compensatory  growth,  there 
may  be  no  interference  with  the  general  health.     (Sehrwald.) 


Fig.  186. 


Fig.  187. 


Destruction  of  kidney  from  hydronephro- 
sis. (Specimen  in  Philadelphia  Hospital  Mu- 
seum.) 


Large  vesical  calculus.  Contracted  hyper- 
trophied bladder,  double  hydronephrosis. 
(Specimen  in  Philadelphia  Hospital  Museum.) 


Intermittent  or  relapsing  hydronephrosis  is  characterized  by  an 
occasional  partial  or  complete  evacuation  of  the  contents  of  the  dilated 
kidney  pelvis,  followed  by  the  passage  of  a  large  quantity  of  urine 
from  the  bladder.  In  one  case,  reported  by  Gintrac,  the  tumor  was 
wont  to  subside  suddenly  by  discharging  into  the  colon,  the  subsidence 
being  followed  by  copious  watery  stools. 


HYDRONEPHROSIS.  593 

The  usual  cause  of  intermittent  hydronephrosis  is  movable  kid- 
ney, the  ureter  being  flexed  or  twisted,  and  remaining  partially  or 
■completely  impervious  till  a  change  in  the  position  of  the  organ  ren- 
ders its  duct  patulous,  and  the  retained  urine  freely  escapes. 

Occasionally  intermittent  hydronephrosis  may  be  due  to  a  calculus, 
which  may  act  as  a  temporary  ball-valve,  closing  the  ureteral  outlet 
from  the  kidney,  but  becoming  dislodged  when  the  pelvis  is  much 
dilated.  After  the  subsidence  of  the  tumor  the  patient  may  be  free 
from  symptoms  for  months,  or  even  years,  or  the  hydronephrosis 
may  recur  frequently. 

Bland  Sutton  calls  attention  to  the  difficulty  of  deciding  clinically 
between  a  very  large  hydronephrotic  cyst  and  an  ovarian  or  par- 
ovarian cyst,  since  cysts  of  the  ovary  and  parovarium  sometimes 
rupture,  and  the  fluid  escaping  into  the  peritoneum  is  absorbed  by 
this  membrane  and  rapidly  excreted  by  the  kidneys,  thus  producing 
the  characteristic  symptoms  of  intermittent  hydronephrosis, — i.e., 
tumor  which  suddenly  disappears  and  is  promptly  followed  by  diu- 
resis. 

In  nearly  all  cases  of  hydronephrosis  the  obstruction  is  not  com- 
plete,— that  is,  there  is  a  partial  escape  of  urine  :  hence,  as  a  rule, 
there  is  hkely  to  be  intermittence  in  degree  of  tension.  Clinically 
the  term  intermittent  is  applied  only  to  those  cases  in  which  the 
swelling  occasionally  disappears  completely. 

Terrier  and  Boudoln  collected  eighty-three  cases  of  intermittent 
hydronephrosis.  They  found  floating  kidney  the  usual  cause,  and 
called  attention  to  the  fact  that  the  disease  eventually  becomes  per- 
manent, owing  to  inflammatory  constrictions  and  adhesions. 

Symptoms. — Unless  sufficient  urine  is  retained  to  produce  a  dis- 
tinct tumor,  there  may  be  no  symptoms  of  hydronephrosis.  The 
obstruction  is  usually  of  such  a  nature  that  retention  is  gradual  and 
painless  in  its  onset,  and  dilatation  of  the  kidney  and  its  pelvis  is  not 
suspected  until  examination  shows  a  smooth,  rounded,  movable, 
fluctuating  tumor  placed  behind  the  colon  and  projecting  into  the 
abdominal  cavity.  The  fluctuation  can  be  detected  only  in  large 
accumulations.  Often  there  is  a  sense  of  weight  and  dragging,  and 
sometimes  there  are  distinct  attacks  of  pain,  resembling  kidney  colic, 
due  to  sudden  increase  of  tension.  Hydronephrosis  develops  without 
fever.  The  intermittent  form  of  the  disease  is  characterized  by  the 
appearance  of  a  tumor  of  rapid  growth,  which  gives  rise  to  pain,  and 
by  sudden  disappearance  of  the  tumor,  followed  by  polyuria.  Pain 
which  develops  during  the  growth  of  the  tumor  may  be  extremely 
severe,  and  may  present  all  the  features  of  kidney  colic.     The  inter- 

38 


594  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

mission  is  sometimes  as  regular  as  are  the  recurrences  of  malarial 
paroxysms. 

Diagnosis. — This  is  based  on  the  detection  of  a  fluctuating  tumor 
primarily  occupying  the  kidney  region.  When  hydronephrosis  is  of 
such  small  dimensions  that  it  cannot  be  felt  by  palpation,  diagnosis 
is  not  possible  except  in  cases  of  acute  ureteral  obstruction  when 
kidney  colic  develops. 

Large  hydronephrotic  sacs  are  readily  confounded  with  ovarian 
cysts,  especially  when  the  evolution  of  the  tumor  and  its  position 
while  still  small  are  unknown.  It  can  readily  be  seen  that  a  sac  con- 
taining thirty  gallons,  as  in  a  case  reported  by  Bland  Sutton,  prac- 
tically fills  the  abdominal  space.  Differential  diagnosis  may  be  im- 
possible. Aspiration  may  throw  light  on  the  etiology  of  the  tumor, 
since  the  contents  of  a  hydronephrotic  sac  may  show  traces  of  urea. 
This,  however,  is  not  always  the  case,  and  it  has  frequently  hap- 
pened that  diagnosis  has  been  made  only  after  incision  for  operation. 
Ureteral  catheterization  may  enable  the  surgeon  to  form  a  correct 
opinion  as  to  the  origin  of  a  cystic  tumor  when  every  other  means 
of  diiferential  diagnosis  fails. 

Prognosis. — The  prognosis  of  hydronephrosis  is  favorable  if  the 
disease  is  unilateral.  Spontaneous  cure  may  result,  probably  from 
atrophy  of  the  secreting  substance  of  the  kidney.  The  more  common 
terminations  are  pyonephrosis  and  pyelonephritis.  When  the  disease 
is  bilateral  the  prognosis  is  extremely  grave. 

Treatment. — No  internal  medication  has  the  slightest  effect  upon 
hydronephrosis.  Antispasmodics  may  possibly  be  serviceable  when 
there  is  reason  to  beheve  that  the  retention  is  due  to  spasmodic  con- 
traction of  the  ureter. 

Surgical  measures  consist  of— (a)  massage  and  manipulation  of 
the  swelling ;  (6)  ureteral  instrumentation  ;  (c)  aspiration  and  tapping 
with  a  trocar  and  canula ;  (d)  nephrotomy,  with  removal  of  the  obstruct- 
ing cause ;  (e)  nephrectomy. 

Massage  and  manipulation  of  the  swelling  have  been  successful 
in  dislodging  the  obstruction  when  it  was  unquestionably  caused  by 
impacted  calculus  or  kinks  in  the  ureter  produced  by  movable  or 
floating  kidney.  Vigorous  kneading  or  rough  handling  of  the  dilated 
pelvis  is  not  safe,  since  there  is  a  chance  of  rupturing  the  sac  into 
the  peritoneal  cavity  or  the  perinephric  tissue.  When  the  manipu- 
lation is  successful  the  tumor  subsides,  and  there  is  a  free  flow  of 
urine  from  the  bladder.  The  subsidence  may  be  permanent  if  the 
obstruction  is  caused  by  impacted  calculus,  but  will  be  only  tempo- 
rary when  it  is  due  to  movable  kidney.  This  temporary  relief  may 
be  made  permanent  by  suturing  the  kidney  in  position. 


HYDKONEPHEOSIS.  595 

Ureteral  catheterization  is  serviceable  when  retention  is  due  to 
stricture  of  the  ureter,  to  valve-formation,  or  to  an  anomalous  en- 
trance of  the  ureter  into  the  pelvis.  It  may  not  only  relieve  tension 
but  may  prove  curative  in  case  of  stricture.  In  using  the  ureteral 
catheter  the  clanger  of  converting  a  hydronephrosis  into  a  pyonephro- 
sis must  be  fully  appreciated  and  guarded  against.  Valve-formation 
should  be  subjected  to  operation. 

Aspiration  is  a  treatment  which  may  be  necessitated  v^^hen  the 
urgency  of  symptoms  calls  for  temporary  relief.  There  is  usually  a 
reaccumulation  of  fluid ;  in  a  certain  number  of  cases  after  emptying 
the  sac  twice  or  thrice  the  secretion  has  ceased  and  the  cure  has  been 
permanent.  This  is  probably  due  to  the  fact  that  the  secreting  sub- 
stance of  the  kidney  has  been  completely  atrophied.  The  operation 
is  not  free  from  risk  of  septic  infection  of  the  sac  and  the  development 
of  pyonephrosis. 

The  best  results  from  puncture  have  followed  when  this  was  prac- 
tised upon  cases  of  traumatic  hydronephrosis.  Morris,  of  eighteen 
cases,  reports  ten  cures,  five  deaths,,  and  three  failures.  In  more 
than  half  the  fatal  cases,  he  states,  further  treatment  should  have 
been  adopted  :  hence  the  apparent  mortality  of  this  procedure  is  far 
too  high.  He  advises,  when  no  particular  spot  is  suggested  by  dis- 
coloration or  prominence,  that  the  needle  should  be  driven  in,  on  the 
left  side,  an  inch  in  front  of  the  last  intercostal  space.  "  If  there  is  no 
indication  for  operating  elsewhere,  the  best  spot  to  select  when  the 
kidney  is  on  the  right  side  is  half-way  between  the  last  rib  and  the 
crest  of  the  ilium,  between  two  and  two  and  a  half  inches  behind  the 
anterior  superior  spine  of  the  ilium."  The  intestine  is  usually  in 
front  of  the  tumor  and  adherent  to  it,  and  may  be  wounded  if  the 
puncture  is  made  too  far  forward. 

Puncture  with  the  trocar  and  canula  is  a  much  more  hazardous 
operation,  and  should  be  discarded. 

When  repeated  aspirations  have  failed  to  give  permanent  relief, 
nephrotomy  is  indicated.  This  operation  may  be  performed  through 
either  the  lateral  abdominal  or  the  lumbar  incision.  The  latter  is 
better,  since  it  not  only  avoids  the  risks  attending  the  opening  of  the 
peritoneal  cavity,  but  also  facihtates  the  performance  of  nephrectomy 
if  that  operation  is  deemed  advisable  after  the  kidney  has  been  ex- 
plored. The  great  objection  to  nephrotomy  is  the  probability  of  the 
development  of  permanent  urinary  fistula.  In  a  certain  number  of 
cases  where  the  secreting  substance  of  the  kidney  has  entirely  disap- 
peared, after  drainage  the  sac  shrivels,  and  there  is  a  good  result ; 
usually  there  is  a  constant  escape  of  urine  and  the  cavity  becomes 


596  GEN^ITO-UEINARY   DISEASES   AND   SYPHILIS. 

infected.  It  is,  therefore,  well,  in  case  nephrotomy  proves  that  it  is 
impossible  to  restore  the  normal  passage  from  the  kidney  pelvis  to 
the  bladder,  to  practise  nephrectomy  before  infection  has  taken  place, 
provided  the  existence  of  a  competent  healthy  kidney  on  the  opposite 
side  is  thoroughly  confirmed. 

Of  eighteen  cases  of  nephrotomy  performed  for  hydronephrosis 
none  proved  fatal.  Bruce  Clark  states  that  in  more  than  fifty  per  cent, 
of  cases  fistula  is  established.  Nephrotomy  is  performed  as  described 
in  the  treatment  of  kidney  calculus.  For  stricture  or  valve  forma- 
tion at  the  uretero-pelvic  junction,  a  plastic  operation  or  section  of  the 
ureter  at  the  lowest  part  of  the  hydronephrotic  sac  is  indicated. 

Nephrectomy  as  a  primary  operation  implies  immediate  removal 
of  the  entire  sac.  The  method  of  operating  is  determined  by  the 
size  of  the  tumor.  When  this  is  extremely  large  the  transperitoneal 
method  is  to  be  preferred,  since  it  allows  freer  access  to  the 
kidney.  In  moderate  dilatation  the  lumbar  incision  is  the  one  of 
choice. 

Arnold  reports  two  deaths  in  twenty-six  cases.  Duplay  and 
Reclus  state  that  nephrotomy  gives  a  mortality  of  eighteen  and  eight- 
tenths  per  cent.,  and  leaves  sixty-six  and  six-tenths  per  cent,  of 
iases  with  fistula ;  nephrectomy  gives  thirteen  and  one-tenth  per 
cent,  mortality  (twenty-five  and  eight-tenths  per  cent,  after  abdom- 
inal incision,  six  and  four-tenths  per  cent,  after  lumbar  incision). 
Secondary  nephrectomy  has  always  been  followed  by  recovery. 
These  calculations  are  based  upon  a  statistical  study  of  fifty-eight 
cases.  Newman  gives  the  mortality  of  nephrectomy  as  forty-one  and 
three-tenths  per  cent. 

TUBERCULOSIS   OF  THE   KIDNEY. 

Tuberculosis  of  the  kidney  presents  itself  in  two  general  forms, — 
acute  and  chronic.  By  the  acute  form  is  meant  the  miliary  infection 
seen  in  cases  of  general  tuberculosis.  Under  the  chronic  form  are 
classified  those  slow  tubercular  lesions  of  the  gland  which  have  been 
generally  known  as  scrofulous  pyelonephritis. 

Acute  renal  tuberculosis  is  quite  common,  particularly  in  the 
young.  In  this  condition  there  is  a  marked  tendency  to  the  involve- 
ment of  the  entire  uro-genital  tract,  but  the  tubercular  deposits  do  not 
attain  the  dimensions  nor  undergo  the  marked  retrograde  changes 
which  are  seen  in  the  chronic  form.  The  renal  lesions  rarely  produce 
definite  symptoms,  and  there  is  no  treatment,  apart  from  that  of  the 
general  infection.  The  presence  of  tubercle  bacilli  in  the  urine  is 
often  of ~  diagnostic  value.     There  are  no  surgical  indications. 


TUBEKCULOSIS   OP   THE   KIDNEY.  597 

Chronic  renal  tuberculosis  may  be  primary  or  secondary,  the 
latter  being  the  rule. 

In  the  primary  infections  the  route  is  probably  haematogenous, 
and,  as  in  the  cases  of  primary  bone  and  gland  tuberculosis,  is  unas- 
sociated  with  tubercular  infection  in  any  other  part  of  the  body ;  the 
mode  of  infection  is  exceedingly  obscure. 

In  the  secondary  infections  the  primary  focus  may  be  in  any  part 
of  the  system  ;  in  comparison  to  the  total  number  of  cases  of  tuber- 
culosis the  kidneys  are  not  frequently  involved. 

The  relations  of  renal  and  uro-genital  tuberculosis  are  not  yet  fully 
understood.  It  seems  clear  that  three  forms  are  encountered :  the 
descending  form,  in  which  the  kidney-lesion  is  primary ;  the  ascending 
form,  in  which  some  one  of  the  subrenal  tissues  is  first  infected ;  and 
the  form  in  which  various  parts  of  the  tract  are  simultaneously  infected. 
Hamill  has  studied  the  well-recorded  cases  in  children,  and  concludes 
that  the  large  majority  of  these  are  of  the  descending  form,  the  kidney 
being  first  infected.  This  also  holds  true  in  regard  to  adults.  Taking 
all  cases  together,  males  are  probably  more  frequently  affected  than 
are  females. 

Renal  tuberculosis  occurs  most  commonly  between  the  ages  of 
twenty  and  forty-five,  though  it  is  by  no  means  confined  to  these 
limits.  One  case  has  been  recorded  in  a  male  infant  three  months 
old,  and  several  cases  have  been  seen  in  persons  aged  more  than 
seventy  years. 

In  the  descending  form  of  tuberculosis  the  condition  in  the  begin- 
ning is  usually  unilateral,  but  later  in  the  course  of  the  disease  the 
other  kidney  becomes  infected  (ascending  infection  from  the  bladder). 
In  the  ascending  form  the  infection  is  usually  bilateral.  In  haemato- 
genous infection  (descending)  the  tubercles  are  first  formed  about  the 
glomeruli  and  the  minute  vessels,  but  these  deposits  may  take  place 
in  any  part  of  the  gland.  They  gradually  break  down,  and  from 
them  the  infection  is  spread  by  the  blood-  and  lymph-channels  and 
by  contiguity.  The  mucous  membrane  of  the  calices  and  pelvis  soon 
becomes  involved,  either  by  distinct  tubercular  formations  or  by  dif- 
fuse infiltration.  The  breaking  down  of  the  aggregated  tubercles  leads 
to  the  formation  of  cavities, — the  so-called  tubercular  cysts.  The 
contents  are  generally  a  yellowish-gray,  blood-tinged  fluid  of  thick 
consistency  and  urinous  odor,  compounded  of  pus,  urine,  blood,  renal 
tissue,  tubercular  matter,  and  detritus,  with  occasional  collections  of 
lime  salts,  phosphates,  and  cholesterin.  Tubercle  bacilli  can  usually 
be  demonstrated  in  the  wall  of  the  cysts,  but  they  are  not  to  be  found 
in  the  contents. 


598  GENITO-URINAEY   DISEASES   AIS"©   SYPHILIS. 

Mixed  infection  is  the  rule  in  the  advanced  cases,  and  pus  organ- 
isms are  found  in  the  cyst  contents.  The  capsule  of  the  kidney  be- 
comes sclerosed  and  thickened,  and  may  present  either  a  diffuse  or  a 
localized  tubercular  infiltration ;  it  is  tightly  adherent  to  the  gland. 
The  total  bulk  of  the  organ  may  be  considerably  enlarged  by  massive 
deposits  and  the  capacity  of  the  pelvis  much  reduced ;  or  after  exten- 
sive degeneration  there  may  be  marked  reduction  in  the  size  of  the 
organ,  due  to  contraction  of  the  connective  tissue  and  the  capsule. 
In  the  course  of  time  the  ureter  is  commonly  affected,  and  its  lumen 
may  be  so  narrowed  that  the  tubercular  kidney  becomes  hydrone- 
phrotic  or  pyonephrotic. 

The  perinephric  tissue  is  always  thickened,  and  may  become 
tubercular  either  by  extension  from  the  true  capsule,  lymphatic 
infection,  or  the  bursting  of  one  of  the  renal  cysts.  Thus  peri- 
nephric abscess  often  complicates  renal  tuberculosis. 

In  cases  of  ascending  tuberculosis  where  a  hydronephrosis  often 
precedes  the  tubercular  infection,  the  process  commences  in  the 
mucous  membrane  of  the  pelvis,  attacks  the  apices  of  the  pyramids, 
and  gradually  extends  towards  the  cortex,  which  it  involves  less 
profoundly  than  is  the  case  in  hsematogenous  infection.  Obstruc- 
tion, with  the  development  of  hydronephrosis  and  pyonephrosis,  is 
commoner  in  the  ascending  form. 

Symptoms. — There  are  usually  no  symptoms  so  long  as  the  renal 
substance  alone  is  affected,  but  pain  develops  when  the  mucous  mem- 
brane of  the  caKces  becomes  involved  or  when  an  abscess  empties  into 
the  pelvis  :  hence  this  is  often  the  first  symptom.  (Rosenstein.)  The 
pain  is  at  first  dull  and  aching,  and  is  referred  to  the  lumbar  region. 
At  times  severe  paroxysms  occur  (renal  colic),  and  the  pain  is  re- 
flected to  the  penis  and  testicles.  Pain  may  be  increased  by  motion 
and  position.  Some  patients  acquire  a  habit  of  lateral  curvature,  with 
the  concavity  towards  the  affected  side,  since  this  position  lessens 
their  suffering.  Urination  may  occasion  severe  pain,  referred  to  the 
vesical  neck. 

Urinary  symptoms  often  occur  early ;  later  they  are  constant. 
They  are  of  great  importance.  Undue  frequency  of  urination  and 
slight  urgency  or  incontinence  are  symptoms  which,  in  the  absence  of 
obvious  cause,  should  always  arouse  suspicion  of  tuberculosis.  (Har- 
rison.) After  infection  the  usual  symptoms  of  cystitis  and  uretero- 
pyelitis  will  develop. 

Early  in  the  disease  the  quantity  of  urine  may  be  normal,  but  is 
often  increased,  constituting  polyuria.  As  soon  as  the  mucous  mem- 
brane becomes  affected,  pus  and  blood  appear  in  the  urine.     Ha^ma- 


TUBERCULOSIS   OF   THE    KIDNEY.  599 

turia  is  usually  slight  and  intermittent ;  it  may  be  constant,  but 
there  is  much  less  blood  than  in  malignant  disease  or  calculous 
pyelitis.  After  the  abscesses  have  once  opened  into  the  pelvis  and 
mixed  infection  has  taken  place,  pyuria  is  constant,  except  when 
the  ureter  becomes  blocked ;  this  comphcation  is  of  frequent  oc- 
currence, but  the  obstruction  is  rarely  permanent.  In  a  fev^  hours 
or  days  the  blocking  material  becomes  dislodged,  and  there  follows 
a  profuse  gush  of  urine,  loaded  with  pus  and  detritus.  At  times  the 
tubercular  matter  in  the  urine  may  be  so  bulky  that  it  is  with  dif- 
ficulty voided.  Albuminuria  is,  of  course,  present  w^henever  the 
urine  contains  blood  or  pus,  but  it  is  usually  dependent  upon  them. 
Sooner  or  later,  however,  parenchymatous  inflammation  occurs  in 
either  the  affected  kidney  or  its  fellow,  and  there  then  develops  an 
essential  albuminuria.  The  urine  is  usually  acid  in  the  absence  of 
pyonephrosis  or  bladder  infection  ;  after  the  advent  of  cystitis  or  when 
there  is  retention  in  the  kidney  pelvis,  with  mixed  infection,  it  is 
alkaline.  It  is  turbid  according  to  the  amount  of  pus  it  contains,  and 
colored  according  to  the  amount  of  blood. 

Microscopically,  pus  and  blood  are  nearly  always  found,  but  clots 
are  rare.  Hyaline  casts  are  commonly  present.  Colombino  asserts  that 
deformed  leucocytes  are  particularly  characteristic.  "Epithelial  cells 
from  the  kidney  and  pelvis  are  constant  in  the  urine  of  cases  with 
advanced  lesions  ;  renal  tissue  is  occasionally  seen  ;  connective  tissue 
and  elastic  fibres  are  sometimes  found,  and  are  of  great  diagnostic 
value,  as  are  the  little  clumps  of  meal-like  detritus  which  look  like 
conglomerated  nuclei  and  resist  all  reagents. 

Tubercle  bacilli  should  be  sought  for  in  all  cases,  but  especial 
care  must  be  taken  that  the  urine  is  fresh  and  that  the  smegma 
bacillus  is  excluded. 

Physical  examination  reveals  symptoms  of  diagnostic  value.  In 
many  cases  a  tumor  is  noted  in  the  loin,  due  to  actual  renal  enlarge- 
ment, to  perinephric  abscess,  or  to  a  hydronephrosis  or  pyonephrosis. 
This  tumor  may  be  outlined  by  percussion  posteriorly,  and  may  be 
felt  through  the  abdominal  walls.  It  may  feel  smooth  or  nodular, 
may  fluctuate,  and  is  generally  tender  on  pressure.  The  enlarged 
ureters  are  sometimes  palpable.  Should  the  left  kidney  be  the  one 
affected,  the  spleen  will  be  pushed  forward  and  the  real  trouble  thus 
obscured.  Cystoscopic  examination  will  generally  show  oedematous 
pouting  of  the  ureteral  eminence  with  hypersemia  or  even  erosions 
about  its  orifice  on  the  side  affected. 

The  patient  suffers  from  progressive  anaemia  and  digestive  disturb- 
ances, with  emaciation  and  cachexia.     Irregular  fever  may  be  present, 


600  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

and  often  assumes  a  hectic  type.  Otlier  tubercular  lesions  commonly- 
develop. 

Diagnosis. — The  diagnosis  of  renal  tuberculosis  is  founded  upon — 
(1)  a  tubercular  family  history ;  (2)  an  otherwise  inexplicable  poly- 
uria ;  (3)  slight,  transitory,  apparently  causeless  haematuria ;  (4)  fre- 
quent urination ;  (5)  pyuria  developing  seemingly  v^ithout  sufficient 
cause  and  persisting ;  (6)  the  formation  of  a  lumbar  tumor ;  (7)  the 
development  of  tubercular  lesions  in  other  parts  of  the  body,  par- 
ticularly in  the  accessible  portions  of  the  genito-urinary  tract ;  (8) 
the  demonstration  of  tubercle  bacilli  by  microscopic  examination  or 
inoculation  ;  (9)  the  development  of  tubercular  cachexia ;  (10)  the 
tuberculin  test. 

The  only  single  sign  which  is  absolutely  diagnostic  is  the  finding 
of  the  tubercle  bacilli.  These  micro-organisms  cannot  be  differentiated 
from  smegma  bacilli  by  staining  reaction  :  hence  in  collecting  the  urine 
care  must  be  taken  to  avoid  contamination  from  the  surface  of  the 
glans  or  the  foreskin. 

Often  a  tubercular  family  history  cannot  be  elicited.  Polyuria  is 
a  very  frequent  and  constant  symptom  of  early  renal  involvement ;  it 
may,  however,  be  excited  by  many  other  causes,  and  is  of  value  from 
a  diagnostic  stand-point  only  when  associated  with  other  symptoms. 
Haematuria  is  to  a  certain  extent  characteristic ;  it  is  distinguished 
from  the  haematuria  caused  by  renal  tumors  by  the  fact  that  the 
amount  of  blood  found  in  the  urine  is  trifling.  Unlike  haematuria 
symptomatic  of  renal  calculus,  it  is  not  markedly  influenced  by  active 
exertion.  Nor  does  it  promptly  disappear  after  rest  in  bed.  Fre- 
quent urination  is  rare,  and  is  commonly  a  sign  of  concomitant  in- 
volvement of  the  bladder ;  it  sometimes  precedes  by  many  months 
the  development  of  appreciable  bladder-lesion,  and  may  be  a  renal 
reflex.  Pyuria  may  develop  suddenly  from  rupture  of  a  cortical 
abscess  into  the  pelvis  of  the  kidney,  profuse  discharge  of  pus  sug- 
gesting this  accident.  It  is  commonly  due  to  ascending,  infection, 
denotes  the  onset  of  pyelonephritis,  and  is  attended  by  the  symp- 
toms of  this  condition. 

The  development  of  a  lumbar  tumor  is  of  diagnostic  value  only 
when  it  is  associated  with  other  characteristic  symptoms  of  renal 
tuberculosis.  There  are  no  peculiarities  of  the  tubercular  enlarge- 
ment which  would  enable  the  surgeon  to  suspect  the  nature  of  the 
growth  from  physical  examination.  When  the  tubercular  kidney 
becomes  infected  with  pus  micro-organisms — and  this  takes  place  in 
nearly  all  cases — the  symptoms  are  simply  those  of  a  pyelitis,  pyelo- 
nephritis,- or  suppurative  nephritis,  the  diagnosis  as  to  the  underlying, 


TUBERCULOSIS   OF   THE   KIDNEY.  601 

tubercular  nature  of  the  affection  then  resting  upon  the  results  of 
bacteriological  examination. 

From  the  operative  stand-point  it  is  of  extreme  importance  to  find 
out  whether  one  or  both  kidneys  is  affected.  This  may  be  deter- 
mined by  ureteral  catheterization,  with  the  subsequent  injection  of  the 
urine  drawn  from  each  kidney  into  susceptible  animals.  This  is  the 
only  reliable  method  of  deciding  as  to  the  health  of  an  apparently  un- 
infected kidney.  Segregation  is  not  sufficiently  accurate  for  this  pur- 
pose. In  the  early  stages  of  renal  tuberculosis  perfectly  limpid  urine 
may  be  ehrainated :  hence  a  diagnosis  based  on  the  discharge  of  clear 
urine  during  periods  when  the  ureter  of  an  obviously  diseased  kidney 
is  blocked  is  unreliable. 

Prognosis. — The  prognosis  is  unfavorable,  especially  when  both 
kidneys  are  involved.  Of  thirty-two  cases  of  renal  tuberculosis, 
Roberts  reports  five  as  dead  six  months  after  the  lesion  was  de- 
tected ;  five  more  died  within  a  year,  three  within  two  years,  one  hved 
beyond  this  period ;  the  remaining  cases  are  unaccounted  for.  The 
course  of  the  lesion  is  much  more  rapid  when  pyelitis  and  pyelone- 
phritis develop.  Le  Dentu  states  that  death  is  usually  caused  by 
cachexia,  renal  insufficiency,  and  gastro-intestinal  catarrh. 

Tuberculosis  is  apparently  more  virulent  when  it  attacks  the  kid- 
ney than  when  it  involves  the  bladder,  prostate,  or  epididymis ; 
spontaneous  cure  may,  however,  take  place  by  a  process  of  caseation 
and  encapsulation. 

Rovsing  holds  that  nephrectomy  should  be  performed  as  soon  as 
the  diagnosis  is  made.  He  further  notes  that  after  removal  of  the 
diseased  kidney  injections  of  one  hundred  cubic  centimeters  of  five 
per  cent,  carbolic  acid  at  body  temperature  repeated  two  or  three 
times  at  intervals  of  two  days  will  cure  the  vesical  tuberculosis  and 
that  tuberculosis  of  the  genital  organs  should  be  removed  at  the  same 
time  the  kidney  is  taken  out. 

Since  the  process  is  an  infectious  one,  the  treatment  which  is  nat- 
urally suggested  is  the  complete  removal  of  the  tubercular  focus.  In 
its  early  stages  the  disease  is  usually  unilateral,  and  may  so  remain 
throughout  its  entire  course.  Hunner  reports  thirty-five  cases  in 
women  ;  in  thirty-one  of  them  but  a  single  organ  was  affected.  When 
the  diagnosis  is  made  early,  and  this  is  usually  possible  from  uri- 
nary examination  and  the  tuberculin  test,  and  when  there  will  be 
left  one  sound,  normally  acting  kidney  as  determined  by  ureteral 
catheterization  and  segregation  (see  page  379),  a  prompt  nephrec- 
tomy with  removal  of  the  ureter  is  indicated,  since  there  is  little 
reason  to  hope  for  a  spontaneous  arrest  of  the  tuberculous  process. 


602  GEXITO-IJEIXAEY   DISEASES    AXD   SYPHILIS. 

This  operation  is  still  more  urgently  indicated  in  unilateral  cases  of 
mixed  infection  characterized  by  pyonephrosis  or  jDerinephric  abscess. 
WTien  both  kidneys  are  involved  nephrectomy  and  drainage  are  indi- 
cated with  the  clear  understanding  on  the  part  of  the  patient  that  per- 
manent fistulse  will  probably  result. 

Kiimmel  reports  thirty-five  cases  of  renal  tuberculosis,  thirty  of 
which  were  subjected  to  nephrectomy  and  five  to  nephrotomy  ;  twenty- 
eight  recovered  ;  while  Kronlein  states  that  of  thirty-four  nephrectomies 
for  tuberculosis,  twenty-four  were  lining  after  from  one  to  fourteen  years. 
In  no  instance  was  death  due  to  insufficiency  of  the  other  kidney. 

In  performing  nephrectomy  in  advanced  cases  it  may  be  found 
that  the  capsule  of  a  kidney  which  has  become  degenerated  as  the 
result  of  tubercular  pyelonephritis  has  contracted  dense  adhesions 
to  surrounding  structures,  and  that  the  loosening  of  these  adhesions 
may  be  impossible  without  opening  the  peritoneum,  tearing  large  ves- 
sels, or  injuring  neighboring  organs  :  hence  it  is  wise  to  practise  sub- 
capsular decortication,  the  kidney  being  stripped  from  its  proper 
capsule  by  the  finger  until  the  hilum  is  reached,  and  the  pedicle  being 
formed  of  the  tissues  in  this  region  by  grasping  them  in  a  large,  strong, 
angled  hcemostatic  forceps.  On  removal  of  the  degenerated  kidney 
mass,  the  vessels  may  be  indi\idually  secured  or  the  pedicle  may  be 
ligated  eji  masse;  it  is  often  extremely  friable,  and  unless  this  portion 
of  the  operation  is  carefully  conducted  there  is  danger  of  serious 
hemorrhage.  The  capsule  is  thoroughly  curetted  and  packed  with 
gauze  when  there  has  been  mixed  infection. 

REXAL   FISTUKE. 

Fistulge  may  form  spontaneously  as  a  result  of  the  rupture  of 
abscesses  secondary  to  pyonephrosis,  pyelonephritis,  or  perinephritis, 
or  may  be  caused  by  traumatism  or  surgical  intervention.  They  may 
pass  down  to  the  kidney  surface,  to  its  glandular  substance,  or  into 
its  pelvis. 

Fistulae  are  named  in  accordance  with  their  direction  and  points 
of  opening  as  reno-cutaneous,  reno-gastric,  reno-intestinal,  and  reno- 
pulmonary. 

Reno-cutaneous  fistulae  usually  open  in  the  lumbar  or  the  inguinal 
region  ;  their  course  is  fairly  direct. 

Reno-gastric  flstulse  are  extremely  rare.  Duplay  and  Reel  us  quote 
Marquezy  as  authority  for  the  statement  that  there  have  been  three 
instances  in  which  kidney  stones  were  expelled  through  the  mouth. 

Reno-intestinal  fistulge  are  comparatively  frequent,  particularly 
those  opening  into  the  colon. 


NEOPLASMS   OF   THE    KIDNEY.  603 

The  causes  of  fistulse  are  incomplete  drainage,  the  presence  of  a 
foreign  body,  as  a  calculus  or  a  drainage-tube,  continuous  profuse  sup- 
puration, as  in  simple  or  tubercular  pyelonephritis,  and  the  constant 
escape  of  urine,  as  in  wound  of  the  pelvis  or  of  the  ureter.  Operative 
fistulge  rarely  develop  except  when  infected  tissues  are  involved  in  the 
incision. 

Symptoms. — The  most  obvious  symptom  of  fistula  is  the  presence 
of  an  ulcerating  opening  from  which  escapes  either  urine  or  pus. 
Because  of  the  continuous  discharge  there  are  usually  marked  ery- 
thema and  dermatitis  about  the  opening.  When  these  fistulse  are  of 
long  standing,  diverticula  are  formed,  the  walls  become  rigid,  and  the 
tract,  though  fairly  direct,  is  sufficiently  tortuous  to  prevent  the  easy 
introduction  of  a  probe. 

Reno-intestinal  fistulse  are  suggested  by  vomiting  or  purging  of 
pus  and  urine.  Reno-bronchial  fistulse  are  characterized  by  an  initial 
profuse  discharge  of  pus,  followed  by  symptoms  much  like  those  of  a 
purulent  pleurisy  which  has  broken  into  a  bronchus. 

Prognosis. — In  the  absence  of  tuberculosis  the  prognosis  of  renal 
fistulse  is  favorable  when  they  open  on  the  surface  ;  there  is  even  a  fair 
prospect  of  spontaneous  cure.  These  fistulae  exhibit  a  tendency  to 
contract  slowly,  thus  rendering  drainage  insufficient.  Exceptionally, 
especially  in  tubercular  cases,  there  is  a  discharge  so  profuse  that  in 
itself  it  is  exhausting  to  the  patient. 

Treatm,ent. — Preventive  treatment  of  fistulge  lies  in  prompt  inter- 
vention in  cases  of  renal  or  perirenal  suppuration.  When  a  fistula 
has  formed  and  persists  in  spite  of  proper  treatment,  free  direct 
drainage  is  indicated,  followed  by  gauze  packing  and  an  effort  to 
make  the  wound  heal  from  the  bottom.  Should  the  fistula  discharge 
urine,  treatment  is  first  directed  towards  rendering  the  ureter  per- 
meable and  of  normal  calibre.  When  this  is  accomplished,  the  kidney 
maybe  exposed  and  freed  from  its  attachments,  the  walls  of  the  renal 
tract  excised,  the  wound  closed  by  catgut  suture,  and  the  parietal 
tract  treated  in  the  same  way. 

If  the  ureter  cannot  be  rendered  pervious,  or  if  the  fistula  comes 
from  a  hopelessly  disorganized  pyelonephritic  kidney,  nephrectomy 
is  indicated,  provided  the  other  kidney  is  healthy. 

NEOPLASMS   OF   THE   KIDNEY. 
Tumors  may  be  grouped  in  two  main  classes, — the  primary  and 
the  secondary. 

The  primary  neoplasms  comprise  the  following : 

A.  Epithelial  Tumors. — Of  these  there  are  several  varieties. 


604  GENITO-TJEIXAPvY   DISEASES   AND   SYPHILIS. 

a.  Adenomata. — Small  single  or  multiple  adenomata  are  of  rather 
frequent  occurrence,  particularly  in  the  contracted  kidney.  Adeno- 
mata must  be  distinguished  from  adrenal  inclusions  and  ectatic  hyper- 
plastic formations.  They  spring  from  the  intratubular  epithelium  ; 
the  cells  are  cuboidal  or  cylindrical,  and  the  acini  have  a  well-formed 
tunica  propria.  Occasionally  an  adenoma  may  attain  very  large  pro- 
portions. The  so-called  alveolar  adenoma  is  really  a  neoplasm  of 
adrenal  structure.  An  especial  variety  is  the  papillary  adenoma, 
which  presents  a  papillary  arrangement.  These  adenomata  may 
become  mahgnant  (nodular  type  of  cancer). 

h.  Carcinomata. — These  develop  from  the  intratubular  epithelium  ; 
in  them  the  urinary  canals  may  to  a  certain  extent  persist,  and  if 
dilated  may  form  large  spaces.  The  much-discussed  intracellular 
formations  of  cancer-cells  (coccidia)  are  well  seen  in  these  growths. 

Cancer  may  be  single  or  multiple,  and  may  attain  tremendous 
proportions.  Two  types  may  be  distinguished :  the  nodular  type, 
including  growths  which  are  adeno-carcinomatous  (adenomatous  at 
the  beginning)  and  exhibit  an  alveolar  arrangement,  with  cuboidal  or 
cylindrical  cells ;  and  the  infiltrating  type,  including  growths  which 
are  cancerous  from  the  beginning  and  show  little  alveolar  structure ; 
their  cells  are  polymorphous. 

In  the  renal  substance  around  the  growth  a  compensatory  hyper- 
trophy may  occur.  More  often  there  is  a  parenchymatous  degen- 
eration with  interstitial  overgrowth ;  at  times  amyloid  degeneration. 
The  central  portions  of  the  growth  often  soften  and  break  down, 
forming  cysts  with  sanguinolent  contents.  The  pelvis  of  the  kidney 
may  be  involved,  then  the  walls  of  the  ureter  and  perhaps  of  the 
blood-vessels,  and  later  the  adrenal  and  the  fatty  capsule  ;  ultimately 
the  infiltration  may  spread  to  the  pancreas  or  the  intestines. 

Clinically,  the  neoplasm  may  be  hard  or  soft,  most  often  soft ;  it 
may  become  colloid  and  may  form  a  fungus  hsematodes.  It  has  been 
found  associated  with  testicular  carcinoma  and  (in  the  aged)  with 
calculus.  In  a  few  cases  the  growth  has  broken  through  the  skin. 
Metastasis  occurs  most  frequently  to  the  retroperitoneal  lymph-glands, 
the  lung,  and  the  hver. 

The  disease  is  more  common  in  children  than  in  adults.  Of  four 
hundred  and  fifty-nine  cases,  one  hundred  and  fifty-seven  were  noted 
in  children  less  than  ten  years  of  age.  Those  next  most  commonly 
affected  are  between  fifty  and  sixty  years  old,  ninety-six  cases  being 
found  during  this  decade.  The  following  statistics  taken  from  Senator 
(NothnagePs  System)  illustrate  the  relations  as  to  the  location  of  the 
tumor  and  the  age  and  sex  most  commonly  affected. 


NEOPLASMS   OF   THE   KIDNEY. 


605 


Cases. 

433       .     . 

Primary  Carcinomata  of  the  Kidney. 

Location. 

Right  kidney.     Left 
201 

kidney. 
190 

Males. 
199 

Males. 
58 

Both  kidneys 
42 

Cases. 
305  .     .     . 

Sex  affected. 

Females. 
106 

Cases. 
96     .     .     . 

Sex 

affected  in  CJiildren  under  Ten  Years 

Females. 
38 

Years. 
0  to  10  . 

Ages  at  which  u 

Cases. 
.     157 

iffection  occurs. 
Years. 
50  to  60  . 
60  to  70  . 
70  to  80  . 

Total 

Cases. 
.      96 

10  to  20  . 

.       15 

.      57 

20  to  30  . 

.       34 

.       13 

30  to  40  . 

.      45 

40  to  50  . 

.      42 

.     459 

Of  cases  in  children  under  ten  years  of  age,  fifty  per  cent,  occur 
during  the  first  two  years  and  eighty-five  per  cent,  during  the  first 
five  years. 

B.  Tumors  of  Connective-Tissue  Origin. 

a.  Fibromata  are  frequent.  Tliey  are  usuaUy  small,  single,  or 
multiple,  hard,  and  spring  from  the  intercanalicular  connective  tissue, 
either  in  the  medulla  or  in  the  cortex. 

6.  LiPOMATA. — True  lipomata  are  rare  ;  they  are  not  encapsulated, 
and  lie  in  the  cortex ;  they  are  probably  developed  from  inclusions 
of  the  fatty  capsule. 

c.  Leucomyomata  (or  lipomyomata). — These  rare  growths  he  in 
the  cortex,  and  are  composed  of  plain  muscle-cells.  They  are  attached 
to  the  capsule,  and  probably  develop  from  embryonal  inclusions  of 
the  capsule  whose  tunica  albuginea  contains  plain  muscular  tissue. 
They  are  likely  to  become  sarcomatous. 

Sarcomata. — These  are  perhaps  the  most  frequent  renal  tumors ; 
small  and  large  round-celled,  spindle-  and  giant-celled,  and  melano- 
sarcomata  are  seen,  usually  mixed.  They  spring  from  the  intertubular 
or  the  subcapsular  connective  tissue. 

Under  the  name  of  angiosarcomata  are  classed  four  types  :  (1)  the 
ordinary  angiosarcoma  with  many  dilated  vessels  possessed  of  endo- 
thelial walls;  (2)  the  vascular  endothelioma,  which  springs  from  the 
endothehum  of  the  veins ;  (3)  the  lymphatic  endothelioma,  springing 
from  the  lymph-tracts ;  and  (4)  the  perivascular  sarcoma,  which 
springs  from  the  cells  of  the  tunica  adventitia  of  the  vessels,  particu- 


606  GENITO-UEINARY  DISEASES  AND   SYPHILIS. 

larly  the  veins,  presenting  marked  hyaline  degeneration  of  the  vessel 
Vi'-alls.     These  often  bleed  profusely. 

Sarcomata  are  most  common  in  children,  the  kidney  in  them  being 
the  favorite  seat  of  malignant  growth,  are  usually  uniliteral,  may  be 
single  or  multiple,  and  grow  rapidly.     Metastasis  occurs,  as  in  cancer. 

Table  of  Primary  Renal  Sarcomata  (from  Senator). 


Years.  Cases. 

0  to    1 7 

1  to    2 9  . 

2  to    6 19 

6  to  10 3 

10  to  20 6 


Years.  Cases. 

20  to  40 3 

40  to  60 8 

60  to  80  ....     .       3 

Total 58 


Females  are  most  frequently  affected ;  the  left  kidney  is  more 
often  involved  than  the  right. 

C.  Tumors  of  Heterogeneous  Origin. 

a.  Tumors  of  suprarenal  origin  (strumse  suprarenalis  aberratse) 
have  often  been  mistaken  for  adenomata.  They  are  generally  small, 
are  found  in  the  cortex  of  the  gland,  and  are  composed  of  the  ele- 
ments of  the  suprarenal  capsules  (epithelium  and  zona  pigmentosa). 
Similar  to  them  is  the  struma  accessoria,  which  is  attached  to  the 
capsule  of  the  kidney,  and  which  may  become  large.  Both  of  these 
growths  contain  much  fat,  and  in  the  cells  is  found  glycogen :  they 
may  undergo  amyloid  or  hyahne  degeneration.  Either  of  these  tumors 
may  assume  the  type  of  a  primary  suprarenal  adenoma ;  they  have 
often  been  mistaken  for  true  renal  adenomata.  They  may  become 
malignant,  and  are  then  probably  to  be  classed  as  carcinomata. 

B.  Rhabdomyomata  are  composed  of  striped  muscle  cells ;  they 
are  rich  in  glycogen,  but  are  often  atypical  in  appearance.  They  gen- 
erally become  sarcomatous,  and  then  grow  to  large  size.  They  occur 
in  children,  and  are,  according  to  the  theory  of  Cohnheim,  like  the 
strumae  suprarenalis  aberratae.  They  may  contain  bone-  and  cartilage- 
cells. 

Secondary  tumors  of  the  kidney  are  generally  dependent  upon 
metastasis  by  either  the  lymphatic  or  the  vascular  route.  One  or 
both  kidneys  may  be  affected ;  the  growths  are  nodular,  and  seldom 
attain  large  size. 

Symptoms  of  Malignant  Tumors  of  the  Kidneys. — The  symptoms  are 
those  of  tumor,  pressure  and  disturbance  of  renal  function.  Pain  is 
an  early  symptom,  but  may  be  absent ;  it  is  dull  and  dragging  in  char- 
acter, and  rarely  radiates  into  the  genitalia. 

The  urinary  signs  are  very  important.     Hfematuria  is  profuse,  in- 


NEOPLASMS   OF    THE   KIDXEY.  607 

termittent,  and  apparently  causeless.  Clots  are  often  passed,  and  the 
ureter  may  be  obstructed  thereby.  Complete  permanent  occlusion 
of  the  ureter,  however,  is  usually  caused  by  direct  pressure  of  the 
tumor.  Portions  of  the  neoplasm  may  be  voided.  Hyaline  casts  are 
common,  granular  casts  rare.  The  hemorrhages  are  in  some  cases 
provoked  by  overexertion  or  traumatism.  Pyuria  is  sometimes  seen. 
Hsematuria  in  a  child  under  seven  years  of  age  strongly  suggests 
malignant  disease. 

Physical  examination  may  furnish  positive  signs.  The  tumor  is 
often  adherent  to  the  posterior  abdominal  wall,  the  small  intestines 
are  pushed  to  one  side,  and  the  colon  lies  upon  the  growth.  As 
a  rule,  there  is  no  movement  upon  respiration,  though  this  is  occa- 
sionaUy  observed  in  cases  of  tumor  of  the  right  kidney.  The  feel 
of  the  tumor  is  hard,  and  may  be  smooth  or  nodular.  Exception- 
ally there  may  be  pulsation  and  a  vascular  murmur.  If  the  colon 
is  alternately  filled  with  air  and  emptied,  percussion  will  show  that 
the  tumor  lies  behind  this  segment  of  the  intestine.  The  spleen 
is  displaced  by  a  tumor  of  the  left  kidney,  and  when  the  growth 
attains  large  dimensions  various  transpositions  of  the  organs  may  be 
seen. 

If  one  hand  be  laid  upon  the  abdomen  and  the  lumbar  region 
gently  tapped  with  the  other  hand,  Guyon's  sign  may  be  ehcited  {bal- 
loUement  renal)^  a  sign  never  produced  by  a  normal  kidney. 

There  are  gastric  and  intestinal  symptoms  (indigestion  and  con- 
stipation), with  occasional  diarrhoea.  Ascites  is  often  present  in  the 
late  stages.  Pressure  upon  the  iliac  veins  or  the  inferior  vena  cava 
may  cause  a  more  or  less  pronounced  oedema  of  the  legs,  while  severe 
neuralgias  with  paresis  may  result  from  pressure  upon  the  ischiatic 
or  other  nerves.  Varicocele  upon  the  side  of  the  kidney  affected  is 
common,  and  is  made  worse  by  standing. 

In  late  stages  the  inguinal  glands  may  become  enlarged.  The  con- 
stitutional symptoms  may  remain  long  in  abeyance.  Sooner  or  later 
the  patient  becomes  anaemic,  and  a  marked  cachexia  finally  develops 
with  mental  derangement  and  an  irregular  fever,  due  probably  to 
urgemia  or  auto-intoxication.  Symptoms  of  metastasis  may  apjDear. 
In  some  cases  a  high  pulse-rate  is  maintained.  Klihn  has  pointed 
out  that  in  children  with  congenital  sarcomata  there  is  often  a  pre- 
cocious development  of  the  pubic  and  axillary  hair  and  of  the  cuta- 
neous pigment. 

Diagnosis. — The  diagnosis  is  founded  upon  profuse  intermittent 
renal  hemorrhage,  the  development  of  a  kidney  tumor  which  is  steachly 
progressive,  and  the  passage  of  fragments  of  neoplasm. 


608  GENITO-URINAKY   DISEASES   AND    SYPHILIS. 

In  the  early  stages  of  tumor  the  diagnosis  is  obscure,  and  the  con- 
dition is  hable  to  be  confounded  with  renal  tuberculosis  and  calculous 
pyelitis.  When,  however,  the  growth  becomes  palpable,  the  fact  that 
it  can  be  felt  by  lumbar  palpation  or  can  be  so  pushed  forward  by 
pressure  from  behind  that  abdominal  palpation  becomes  much  easier, 
is  highly  characteristic  of  renal  tumor. 

Cancer  of  the  colon  may  closely  simulate  renal  neoplasm ;  auscul- 
tatory percussion  may  aid  in  distinguishing  between  these  two  affec- 
tions. Moreover,  primary  involvement  of  the  colon  is  more  com- 
monly complicated  by  partial  or  complete  intestinal  obstruction  and 
by  the  passage  of  blood-stained  fseces  without  haematuria.  Kidney 
neoplasm  rarely  infiltrates  the  colon.  The  lateral  position  of  renal 
tumors  and  the  lumbar  bulge  is  in  contrast  to  the  central  position  of 
growths  arising  from  retroperitoneal  lymph-glands. 

Pancreatic  cysts  can  scarcely  be  distinguished  from  renal  enlarge- 
ments. Minkowsky's  method  of  colonic  distention  with  liquid  may 
prove  serviceable  in  differentiating  between  the  two  affections.  When 
the  colon  is  filled  with  water  the  kidney  tumor  is  thrust  back  into  the 
lumbar  region. 

Tumors  of  the  suprarenal  capsule  do  not  often  reach  great  size. 
Differential  diagnosis  between  these  tumors  and  those  of  the  kidney  is 
impossible. 

From  large  pelvic  tumors  renal  growths  may  be  distinguished  by 
the  fact  that  if  the  patient  be  placed  in  the  Trendelenburg  position 
there  may  be  demonstrated  a  tympanitic  area  between  the  pelvis  and 
the  lower  border  of  the  kidney  tumor. 

The  intermittent,  profuse,  apparently  causeless  bleeding  of  renal 
neoplasm  is  simulated  only  by  suppurative  nephritis,  purpura,  and 
hEemophilia.  Other  symptoms  of  these  conditions  will  suggest  their 
presence ;  the  method  of  distinguishing  between  vesical  and  renal 
bleeding  has  been  given  already.  Bleeding  from  renal  calculus  is 
usually  excited  by  exercise  or  jarring,  and  is  promptly  and  favorably 
influenced  by  rest ;  it  is  not  often  sufficiently  pronounced  to  cause 
clots :  none  the  less,  in  a  reported  case  operation  was  undertaken 
for  the  removal  of  kidney  calculus  when  the  condition  present  was 
tumor.  Bleeding  from  tubercular  kidney  is  slight,  but  may  be  severe. 
The  presence  of  the  tubercle  bacillus  is  sometimes  the  only  possi- 
ble means  of  making  a  differential  diagnosis.  Differential  diagnosis 
between  epithelioma  and  sarcoma  is  not  possible. 

Prognosis. — Roberts  has  pointed  out  the  relatively  slow  course  of 
malignant  infiltration  when  it  attacks  the  kidney.  Thus,  there  have 
been  undoubted  cases  of  renal  cancer  which  have  survived  many 


CYSTS   OF   THE   KIDNEY.  609 

years  (ten  to  fifteen).  Sarcomatous  patients  live  two  or  three  years ; 
in  epithelioma  the  duration  of  life  is  somewhat  longer.  Death  usu- 
ally results  from  metastasis  and  asthenia ;  exceptionally  from  haema- 
turia  or  renal  insufficiency.     The  ultimate  prognosis  is  absolutely  bad. 

Treatment. — The  treatment  of  malignant  tumors  of  the  kidney  can 
be  only  palliative  in  the  great  majority  of  cases,  symptoms  being  met 
as  they  arise.  Occasionally  cases  are  reported  of  successful  and  per- 
manently curative  removal  of  these  growths.  Success  is  the  excep- 
tion ;  and  permanence  implies  a  certain  period  of  exemption,  which, 
when  it  lasts  two  or  three  years,  is  likely  to  be  prolonged  indefinitely. 
When  a  tumor  is  recognizable  from  the  exterior  its  extension  is  usu- 
ally too  wide  to  justify  the  expectation  that  nephrectomy  will  enable 
the  surgeon  to  remove  all  the  scattered  deposits  of  disease.  As  yet 
but  few  operative  cases  have  gone  beyond  the  three-year  limit. 

The  kidney  may  be  removed  by  the  oblique  lumbar  incision  ;  one 
which  gives  plenty  of  room  is  imperative.  This  may  involve  length- 
ening the  ordinary  lumbar  cut  or  carrying  a  second  cut  forward  trans- 
versely, or  resection  of  the  last  rib.  If,  after  opening  down  to  the 
kidney,  examination  shows  that  it  is  impossible  to  remove  the  tumor 
entirely,  the  wound  should  be  closed  and  the  idea  of  further  inter- 
vention abandoned. 

The  wound  should  be  closed  by  suture.  In  operations  for  the 
removal  of  malignant  growth  the  renal  vein  may  readily  be  torn  in 
delivering  the  tumor.  Injury  to  the  vena  cava  is  an  occasional  com- 
plication of  nephrectomy. 

In  regard  to  the  advisability  of  operation,  Duplay  and  Reclus  hold 
that  if  we  consider  the  normal  evolution  of  the  disease,  which  some- 
times lasts  for  six  years  from  the  appearance  of  the  first  symptoms,  it 
seems  proper  to  conclude  that  the  efficiency  of  nephrectomy  is  yet  to 
be  proved.  It  can  be  regarded  only  as  a  palliative  operation  planned 
for  the  relief  of  pain  and  hasmaturia.  It  is,  however,  to  be  hoped 
that  very  early  intervention  may  demonstrate  its  curative  power. 

CYSTS   OF  THE   KIDNEY. 

Cysts  of  the  kidney  are  of  three  classes, — simple  cysts,  multilocular 
cysts  (polycystic  diseases),  and  hydatid  cysts. 

Simple  cysts  are  either  due  to  constriction  of  the  urinary  canals 
or  of  the  neck  of  the  capsule  of  Bowman,  or  are  true  adenocystomata. 
They  may  be  single  or  double,  unilateral  or  bilateral,  small,  or  so 
large  as  to  constitute  a  clinical  tumor.  Contracted  kidneys  often  con- 
tain these  cysts.  They  may  involve  either  extremity  of  the  kidney 
(usually  the  upper),  or  its  mid-portion. 

39 


610 


GENITO-UEINAPvY   DISEASES   AND    SYPHILIS. 


Agglomerated  cysts  are  probably  of  two  varieties, — the  con- 
genital and  the  acquired. 

Congenital  cystic  disease  of  the  kidney  is  due  either  to  malformation 
(these  cysts  are  often  accompanied  by  other  uro-genital  deformities) 
or  to  intra-uterine  renal  disease  (embryonal  nephritis  papillaris) ;  the 
kidneys  at  birth  present  more  or  less  cystic  degeneration,  which  leads 
to  early  death  through  visceral 
compression  and  dyspnoea  ;  in 
some  cases  the  organs  have 
been  so  large  at  birth  as  to 
cause  dystocia.  In  advanced 
cases  the  entire  dand  is  con-  ^ 

Fig.  188.  (■ 


Fig.  189. 


Cyst  of  the  kidney.    (Specimen  in  Phila- 
delphia Hospital  Museum.) 


Large  cyst  of  the  kidney.    (Specimen  in  Phila- 
delphia Hospital  Museum.) 


verted  into  a  mass  of  cysts,  although  some  renal  tissue  may  be  preserved. 
Exceptionally  the  disease  remains  latent,  becoming  active  later  in  life. 
Acquired  cystic  disease  differs  little  in  appearance  from  the  con- 
genital form,  except  that  there  is  more  renal  tissue  left  intact  and  that 
there  are  evidences  that  the  growth  was  originally  an  adenocystoma. 
It  occurs  from  the  fortieth  to  the  sixtieth  year,  is  usually  bilateral, 
and  is  often  accompanied  by  cystic  degeneration   of  the   liver  and 


PAKASITES   OF   THE   KIDNEYS.  QH 

sometimes  .by  bronzing  of  the  skin.  In  some  cases  it  has  seemed  to 
follow  an  injury  to  the  lumbar  region.  The  contents  of  all  these 
cysts  are  highly  albuminous,  and  may  be  partly  colloid.  Newman 
has  even  described  colloid  plugs  in  the  urinary  canals.  Blood  may 
be  present.  The  high  percentage  of  albumen  distinguishes  the  fluid 
from  that  of  a  hydronephrosis. 

Symptoms. — The  symptoms  of  renal  cysts  are  those  of  nephritis, 
pressure,  and  tumor. 

Signs  of  nephritis  are  present  in  nearly  all  cases  (although  they 
may  be  long  deferred),  and  with  them  are  signs  of  cardiac  hyper- 
trophy. Albumen  may  be  present  or  absent  from  the  urine,  but 
slight  intermittent  hemorrhages  occur.  The  patients  rarely  complain 
of  sharp  pain.  The  pressure  of  the  growth  may  cause  oedema  and 
pain  in  the  legs.     Ultimately  cachexia  becomes  marked. 

The  simple  cysts  which  attain  large  dimensions  simulate  hydro- 
nephrosis. 

In  polycystic  disease  the  tumor  preserves  the  general  form  of  the 
kidney  ;  fluctuation  is  usually  very  indistinct. 

Tumor,  haematuria,  and  lumbar  pain,  if  accompanied  by  oedema, 
polyuria,  albuminuria,  and  symptoms  of  uraemia,  are  characteristic  of 
cystic  degeneration  of  the  kidneys. 

Treatment. — Simple  cysts  are  treated  by  puncture,  drainage,  par- 
tial nephrectomy,  or  total  nephrectomy.  Puncture  is  commonly  fol- 
lowed by  recurrence.  Drainage  results  in  the  formation  of  a  fistula 
in  the  majority  of  cases,  for  the  cure  of  which  secondary  nephrectomy 
is  required. 

Partial  nephrectomy  is  the  operation  of  choice  when  this  is  prac- 
ticable. Bleeding  from  the  renal  tissue  may  be  troublesome,  but  can 
usually  be  controlled  by  deep  catgut  sutures,  or,  if  these  fail,  by  packing. 

Nephrectomy  is  often  required  because  of  the  position  and  size  of 
the  cyst.  When  the  tumor  is  large,  the  abdominal  route  should  be 
chosen.  When  small,  the  .kidney  may  be  removed  through  a  lum- 
bar incision.  Tuffier  has  collected  twenty-four  cases  of  laparo- 
nephrectomy  performed  for  the  rehef  of  simple  cyst ;  the  mortality 
was  forty  per  cent. 

Cystic  degeneration  does  not  admit  of  surgical  intervention,  since 
the  affection  is  usually  bilateral.  Many  patients  live  for  years  and 
die  of  cardio-renal  disease  or  some  intercurrent  affection. 

PARASITES  OF   THE   KIDNEYS. 
Echinococcus. — The  kidney  is   affected  only  in   from   five   to 
eight  per  cent,  of  all  cases  of  hydatid  disease,  and  the  process  is  gen- 


6X2  GENITO-UKINAKY  DISEASES   AND   SYPHILIS. 

erally  confined  to  one  kidney  (usually  the  left).  Any  part  of  the 
gland  may  be  affected,  but  the  primary  cyst  forms  in  the  cortex. 
The  arrangement  is  that  of  the  echinococcus  hydatidosus.  The  cysts 
may  become  very  large  (eight  inches  in  diameter),  but  are  usually  the 
size  of  an  orange ;  they  exhibit  a  tendency  to  protrude  into  the  ab- 
dominal cavity,  may  contract  adhesions  to  the  abdominal  walls  and 
to  the  viscera,  and  may  rupture  into  the  pelvis,  ureter,  intestines, 
stomach,  pleura,  or  bronchi,  rarely  into  the  peritoneum  or  through 
the  lumbar  muscles.  Suppuration  may  occur  spontaneously  in  the 
unruptured  cyst  or  may  be  provoked  by  traumatism  ;  septic  absorp- 
tion usually  follows,  and  general  pysemia  results.  The  contents  of 
the  cyst  are  slightly  albuminous  or  mucoidal  and  contain  the  booklets. 
Hydatid  cysts  may  coexist  in  other  parts  of  the  body. 

Symptoms. — There  is  very  little  acute  pain  in  connection  with  hyda- 
tid renal  disease  ;  there  is  often  a  sense  of  discomfort  and  of  dragging ; 
finally,  pressure-pains  develop,  but  not  until  the  disease  is  over  a 
year  old.  When,  however,  the  cyst  ruptures  into  the  pelvis  a  ureteral 
colic  is  provoked,  with  very  severe  paroxysms  of  pain ;  the  ureter 
may  be  plugged  by  tissue  or  by  a  daughter  cyst,  with  temporary  or 
permanent  hydronephrosis.  In  a  few  cases  a  general  urticaria  has 
followed  the  evacuation  of  the  cyst. 

In  the  event  of  a  rupture  positive  diagnosis  should  be  made  by 
urinary  analysis.  After  rupture  the  cyst  becomes  infected  and  sup- 
purates, with  the  production  of  a  pyonephrosis.  In  a  few  cases  direct 
symptoms  have  been  excited  by  pressure  upon  veins.  Frequent  uri- 
nation was  the  chief  symptom  in  a  case  of  Tail's. 

The  tumor  is  round,  and  may  be  tender  on  pressure  ;  it  may  feel 
hard  or  may  fluctuate  distinctly ;  the  hydatid  thrill  is  rarely  elicited 
in  renal  cysts. 

Diagnosis. — Hydatid  cysts  are  ordinarily  to  be  confused  only  with 
hydronephrosis  or  ovarian  cysts.  In  the  absence  of  urinary  signs  the 
cyst  may  be  aspirated  for  diagnostic  purposes,  and  tissue,  the  booklets, 
and  succinic  acid  sought  for. 

Treatment. — Recovery  after  spontaneous  evacuation  is  very  rare. 
The  only  treatment  to  be  considered  is  operative.  Four  operations 
have  been  resorted  to  for  the  cure  of  hydatids  : 

1.  Simple  evacuation,  followed  by  closure  or  the  injection  of 
iodine ;  this  is  an  unsatisfactory  treatment,  and  the  cures  are  few. 

2.  Open  incision.  The  entire  cyst  is  evacuated,  as  much  of  the 
cyst-wall  as  possible  excised,  the  edges  of  the  remaining  portion  of 
the  cyst  sewed  to  the  abdominal  incision,  and  the  sac  packed  and  left 
to  granulate. 


THE   SUPEAKENAL  CAPSULES.  613 

3.  Open  incision,  complete  evacuation  of  contents,  followed  by  the 
application  of  a  five  per  cent,  solution  of  carbolic  acid  and  closure 
of  the  cyst  without  drainage.  This  method  has  given  good  results, 
but  the  cyst  should  be  fastened  to  the  parietal  wall,  so  that  subsequent 
drainage,  if  necessary,  will  be  easily  accomphshed. 

4.  Excision  of  the  cyst,  with  partial  or  complete  nephrectomy 
as  may  be  necessary.  Extensive  adhesions  may  contra-indicate  this 
procedure. 

Incision  with  free  drainage  is  usually  successful. 

Strongylus  gigas,  or  "  pahsade  worm,"  is  a  parasite  of  animals, 
the  presence  of  which  in  the  kidney  of  man  is  doubted. 

DisTOMA  H^MATOBiuM  is  a  parasite  observed  among  the  Fellahs  and 
Copts.  The  worm  lives  in  the  portal  vein  and  its  branches.  The 
eggs  are  found  in  the  capillaries  of  the  mucous  membrane  of  the 
urinary  tract.     Diagnosis  is  based  on  finding  the  eggs  or  embryos. 

Pentastoma  denticulatum  has  been  found  on  post-mortem  exami- 
nation in  the  kidney  of  man. 

Spiroptera  hominis  and  Dactylius  aculeatus  have  been  found  by 
Rayer  in  the  urine.  (For  detailed  description  of  these  parasites,  see 
Leuckart,  "  Die  thierische  Parasiten.") 

THE   SUPRARENAL   CAPSULES. 

A  few  cases  of  adrenal  suppuration,  probably  tubercular ;  glandular 
proliferation  ;  and  large  adenoma  have  been  reported. 

Rayer  has  observed  in  infants  various  neoplasms ;  of  these,  lipo- 
mata,  adenomata,  cysts,  angiomata,  fibromata,  carcinomata,  and  sar- 
comata have  been  reported.  The  non-malignant  growths  have  not 
been  subjected  to  surgical  intervention.  Malignant  tumors  are  mainly 
sarcomata,  and  more  than  one-third  of  the  recorded  cases  have  been 
observed  in  infancy.  They  become  adherent  to  the  kidney  and  are 
indistinguishable  from  growths  of  this  organ.  The  symptoms  of 
malignant  infiltration  are  those  of  tumor  of  the  kidney,  with  the  excep- 
tion of  the  alterations  in  the  urine.  These  also  may  be  found,  since 
the  kidneys  are  secondarily  involved.  Morris  gives  as  characteristic 
features  of  adrenal  neoplasm  progressive  weakness  and  emaciation, 
gastro-intestinal  disturbances,  very  movable,  rapidly  growing  tumors, 
and  pigmentation  of  the  skin  and  pronounced  growth  of  the  body  hair. 

Treatment. — Removal  of  the  growth  is  the  only  treatment  to  be 
considered.  Metastasis  is  so  rapid  that  this  affords  little  hope  of  cure. 
The  abdominal  route  is  to  be  preferred.  The  kidney  should  be  saved 
unless  there  are  distinct  evidences  of  adhesion  between  it  and  the 
diseased  suprarenal  capsule. 


^X4  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

Hypernephroma  is  an  overgrowth  of  included  adrenal  tissue,  yel- 
low in  color  and  distinctly  outlined  from  the  substance  of  the  organ  in 
which  it  grows.  It  may  remain  benign  for  a  long  period,  or  while  locally 
latent  may  cause  fatal  metastases.  The  growth  is  at  times  extremely 
vascular  and  may  pulsate.  It  is  prone  to  give  metastases  by  way  of  the 
venous  channels,  particularly  in  the  lungs  and  regional  lymphatic  glands. 

Symptoms. — These  are  those  of  renal  tumor.  It  is  the  usual  renal 
tumor  of  the  adult.  In  its  early  development  hypernephroma  is 
placed  in  the  upper  pole  of  the  kidney.  It  is  sometimes  associated 
with  an  asthenia  characteristic  of  Addison's  disease  and  very  excep- 
tionally with  skin  pigmentation.  A  sudden  causeless  hematuria,  either 
slight  or  profuse,  may  be  the  first  symptom  which  directs  attention 
toward  the  kidney.  A  general  and  pronounced  overgrowth  of  the  hair 
has  been  noted,  and  hypertrophy  of  the  genitalia  is  so  common  that 
a  diagnosis  has  been  formulated  on  this  phenomenon  associated  with 
the  presence  of  a  renal  tumor.  High  blood-pressure  and  tachycardia 
are  suggestive  symptoms. 

Treatment. — This  should  be  that  applicable  to  malignant  growths. 
Cysts  of  the  Suprarenal  Capsule, — Terrier  and  Lecene  con- 
tribute to  literature  two  echinococcus  cysts.  True  glandular  cysts  are 
not  only  extremely  rare  but  seldom  attain  considerable  size,  hence  are 
not  of  great  clinical  importance.  Cysts  of  embryonal  origin  due  to  the 
intra-glandular  inclusion  of  Wolffian  debris  also  arouses  scientific  rather 
than  clinical  interest. 

Cystic  adenomata  are  somewhat  more  frequent  than  glandular  cysts; 
but  are  of  very  small  volume  and  diagnosed  only  post  mortem. 

Serous  cysts,  or  cystic  lymphangiomata  are  commoner  than  the 
glandular  cyst  and  attain  considerable  size.  The  authors  have  collected 
nine  such  cases.  It  is  probable  that  some  of  these  serous  cysts 
become  hemorrhagic. 

Pseudo  cysts  may  have  for  their  origin  hemorrhage  and  necrobiosis 
of  either  the  normal  or  diseased  suprarenal  gland.  Hemorrhages  may 
be  due  to  traumatism  or  may  occur  in  the  course  of  infectious  diseases, 
leukemia,  diabetes,  and  nephritis  or  intoxications.  These  cysts  are 
always  unilateral,  hence  do  not  give  rise  to  the  symptoms  of  Addison's 
disease.  Symptoms  are  varying  and  the  diagnosis  almost  impossible. 
The  tumor  grows  very  slowly  (years)  in  the  hypochtandriac  region,  is 
thoraco-abdominal  in  its  development  and  becomes  prominent  beneath 
the  costal  margin  to  the  right  or  left.  Even  after  operation  the  origin 
of  the  cyst  may  be  left  in  incertitude. 

The  treatment  consists  either  in  marsupilization  or  complete  extir- 
pation, depending  upon  the  extent  and  closeness  of  adhesion. 


CHAPTER  XVIII. 

INJURIES    AND    DISEASES    OF    THE    SCROTUM    AND    TESTICLES. 

Anatomy. — The  scrotum  is  a  pouch  of  skin  and  dartos. 

The  skin  is  provided  with  numerous  sebaceous  follicles  and  a  few 
hairs,  and  after  maturity  becomes  pigmented.  It  generally  exhibits 
folds  or  rugse  passing  at  right  angles  to  the  raphe. 

The  dartos  is  composed  of  connective  tissue  and  smooth  muscular 
fibres.  This  is  continuous  with  the  superficial  fascia  of  the  groin  and 
perineum,  and  forms  at  a  position  corresponding  to  the  raphe  an  in- 
complete septum  partially  separating  the  two  sides.  This  tissue  is 
closely  attached  to  the  skin,  and  is  abundantly  supphed  with  blood- 
vessels. By  its  contraction  it  draws  the  skin  of  the  scrotum  into 
folds  and  holds  the  testicles  up  near  the  position  of  the  external  rings. 
The  contraction  of  this  muscular  tissue  is  occasioned  by  sexual  excite- 
ment, by  cold,  or  by  mechanical  stimulus. 

Beneath  the  dartos  there  is  a  layer  of  loose  ceHular  tissue  on  which 
the  muscular  skin  layers  are  freely  movable,  and  into  the  meshes  of 
which  blood  effusions  or  dropsies  may  readily  occur. 

The  blood-supply  to  the  scrotum  is  derived  from  the  external  pudic 
artery,  the  superficial  branch  of  the  internal  pudic  artery,  the  cre- 
masteric artery,  and  the  artery  of  the  vas  deferens.  The  lymphatics 
are  received  by  the  inguinal  glands. 

The  points  of  practical  value  to  be  gathered  from  a  consideration 
of  the  anatomy  of  the  scrotum  are :  (1)  from  the  close  attachment  of 
the  dartos  to  the  skin,  the  latter  when  wounded  is  liable  to  be  in- 
verted, thus  making  perfect  apposition  difficult  in  suturing  incisions 
of  this  portion  of  the  body  ;  (2)  in  consequence  of  the  loose  texture  of 
the  cellular  tissue  lying  within  the  dartos  and  the  abundant  vasculat- 
ity  of  the  scrotum,  bleeding  incident  to  traumatism  is  free  and  is  likely 
to  form  large  accumulations ;  (3)  on  account  of  this  same  arrange- 
ment, oedema  of  the  scrotum  is  pronounced  from  comparatively  slight 
causes,  and  when  septic  infection  takes  place  there  are  apt  to  be  rapid 
extension  and  sloughing. 

The  testicles  are  the  two  glandular  organs  w^hich  secrete  the 
spermatozoa.  They  are  held  in  position  by  the  spermatic  cord,  and 
are  covered  by  the  scrotum.     They  are  developed  within  the  ab- 

615 


616 


GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 


domen  about  the  eighth  month  of  foetal  Hfe,  They  then  descend 
into  the  scrotum,  being  drawn  down  by  a  musculo-fibrous  cord— 
the  gubernaculum  testis — which  is  attached  above  to  the  base  of 
the  epididymis  and  below  to  the  scrotum.  Lockwood  states  that  at 
the  sixth  to  the  eighth  month  of  intra-uterine  life  many  of  the  lower 


Fig.  190. 


Fig.  191. 


Fig.  190.  Left  testis.  1,  outer  surface ;  2,  2,  antero-inferior  surface ;  3,  posterosuperior  surface ; 
4,  anterior  extremity,  with  hydatid  of  Morgagni ;  6,  postero-inferior  extremity  ;  7,  epididymis ;  8,  its 
head  ;  9,  its  tail ;  10, 10, 10,  deferent  canal ;  11, 11,  spermatic  artery ;  12,  anterior  spermatic  veius  sur- 
rounding the  artery  ;  13,  posterior  spennatic  veins. 

Fig.  191.  Left  testis.  1,  inner  surface ;  2,  antero-inferior  surface ;  3,  anterior  extremity  sur- 
mounted by  Morgagni's  hydatid ;  4,  postero-inferior  surface ;  5,  head  of  the  epididymis ;  6,  tail ; 
7,  7,  deferent  canal  accompanied  by  the  deferential  artery ;  8,  8,  spermatic  artery ;  9,  anterior  sper- 
matic plexus ;  10,  posterior  spermatic  plexus.    (Sappey.) 


fibres  extend  into  Scarpa's  triangle  and  the  perineum  ;  this  may  ex- 
plain the  occasional  presence  of  the  testicle  in  these  regions.  They 
carry  in  their  course  certain  coverings  derived  from  the  peritoneum. 

The  testis  is  a  gland  of  oval  form  ;  it  is  hung  obliquely  in  the 
scrotum,  the  upper  extremity  being  directed  forward  and  slightly  up- 
ward.    (Figs.  190,  191.)     It  has   flattened  sides  and  is  of  variable 


Fig.  192. 


Showing  the  relations  and  coverings  of  the  testicle  and  epididymis.    (Testut.) 


INJURIES  AND  DISEASES  OF   THE  SCROTUM  AND  TESTICLES.     61 7 

dimensions,  but  commonly  is  one  and  a  half  inches  or  more  long,  an 
inch  broad,  and  an  inch  and  a  quarter  from  behind  forward.  The 
weight  of  each  gland  is  from  three-quarters  of  an  ounce  to  one  ounce, 
and  the  left  is  somewhat  larger  than  the  right. 

The  front  and  sides  of  the  testis  are  convex  and  smooth  and  are 
covered  with  the  visceral  layer  of  the  tunica  vaginahs.  The  tunica 
vaginalis  is  derived  from  the  peritoneum  during  the  descent  of  the 
testicle  in  foetal  life.  It  is  the  serous  covering  of  the  testis,  and  is 
composed  of  two  layers, — an  inner  visceral  and  an  outer  parietal. 
The  inner  visceral  portion  forms  a  close  investment  for  the  testicle 
and  epididymis,  while  the  outer  parietal  portion  is  a  loose  sac  invest- 
ing the  testis  and  extending  for  some  distance  up  the  cord.  The 
proper  covering  of  the  testicle  is  the  tunica  albuginea.  This  is  a 
tough,  fibrous  investment,  composed  of  bundles  of  white  fibrous  tis- 
sue, which  interlace  in  every  direction.  It  is  covered  everywhere 
by  the  tunica  vaginalis,  except  at  the  points  of  attachment  to  the  epi- 
didymis. At  the  posterior  portion  of  the  gland  the  tunica  albuginea 
is  inverted  into  the  interior  and  forms  an  imperfect  septum, — the 
mediastinum.  It  extends  from  the  upper  nearly  to  the  lower  border  of 
the  gland ;  from  it  numerous  septa,  called  trabeculae,  radiate  towards 
the  surface  of  the  testicle,  dividing  the  interior  of  the  latter  into  many 
incomplete  spaces,  conical  in  shape,  with  their  bases  towards  the  sur- 
face. The  trabeculae  serve  to  maintain  the  general  shape  of  the  organ, 
to  convey  the  numerous  blood-vessels  that  ramify  in  its  interior,  and 
to  act  as  supports  to  the  glandular  structure  of  the  testicle,  which  is 
made  up  of  lobules. 

These  lobules,  in  accordance  with  the  arrangement  of  the  tra- 
beculae, which  in  each  testicle  have  been  variously  estimated  at  from 
one  hundred  and  fifty  to  four  hundred  in  number,  are  pyramidal  in 
shape.  (Fig.  193.)  According  to  their  size,  the  glandular  lobules  are 
made  up  of  three  or  more  convoluted  seminiferous  tubes,  of  which 
there  are  more  than  eight  hundred,  variously  estimated  as  being  from 
two  to  sixteen  feet  in  length.  It  is  in  these  tubes  that  the  sperma- 
toblasts which  subsequently  become  converted  into  spermatozoa  are 
formed,  Tiiey  begin  in  caecal  extremities  or  by  intercommunication 
with  other  tubes,  and  as  they  approach  the  apices  of  the  cones  they 
become  much  less  convoluted,  finally  uniting  to  form  twenty  or  thirty 
ducts,  which  from  their  straight  course  are  named  the  vasa  recta. 
These  vessels  pass  upward  and  backward,  penetrate  the  mediastinum, 
and  form  an  anastomotic  net-work  made  up  of  channels  in  the  fibrous 
tissue  without  proper  walls  and  termed  the  rete  testis.  These  chan- 
nels terminate  at  the  upper  end  of  the  mediastinum   in  twelve  to 


618 


GEjSriTO-UKINAKY   DISEASES   AND  SYPHILIS. 


twenty  ducts,  called  the  vasa  efferentia,  which  perforate  the  tunica 
albuginea,  and  convey  the  seminal  secretion  to  the  upper  part  of  the 
epididymis;  they  are  at  first  straight,*but  subsequently  become  en- 
larged and  convoluted,  forming  the  coni  vasculosi,  which  collectively 


Fig.  193 


Fig.  193.  The  lobules  of  the  tebtih,  the  rate  vasculosum,  the  eflferent  vessels,  and  the  epididy- 
mis. 1, 1, 1,  seminiferous  lobules  of  the  te'^tes  ;  2,  rete  vasculosum ;  3,  3,  efferent  canals ;  4,  4,  4,  canal 
of  the  epididymis ;  5,  vas  aberrans ;  6,  its  entrance  into  the  epididymis  ;  7,  origin  of  the  convoluted 
portion  of  the  vas  deferens  ;  8,  vas  deferens. 

Fig.  194.  1,  efferent  canal,  showing  its  comparatively  large  calibre  and  straight  direction ;  2, 
beginning  convolutions  ;  3,  cone  formed  by  the  convolutions ;  4,  opening  of  the  convoluted  tube  into 
the  canal  of  the  epididymis ;  5,  5,  the  canal  of  the  epididymis  unravelled.    (Sappey.) 

constitute  the  globus  major,  or  upper  enlargement  of  the  epididymis. 
(Fig.  194.)  The  efferent  vessels  finally  open  into  a  single  duct,  the 
canal  of  the  epididymis,  which  constitutes  by  its  convolutions  the 
body  and  globus  minor  of  the  epididymis,  measuring  in  its  natural 
state  about  three  inches  in  length,  but  when  unravelled  nearly  twenty 
feet.  The  convolutions  are  held  together  by  areolar  tissue  ;  the  inte- 
rior of  the  canal  is  Kned  by  columnar  ciliated  epithehum. 

In  foetal  life  the  head  of  the  epididymis,  its  canal,  the  vas  deferens, 
and  the  ejaculatory  duct  are  formed  from  the  canals  and  ducts  of  the 
Wolffian  body.  The  vas  aberrans  is  formed  from  the  same  body, 
persisting  as  a  canal,  running  upward  from  the  lower  part  of  the  epi- 
didymis or  the  commencement  of  the  vas.  The  pedunculated  body 
called  the  hydatid  of  Morgagni,  found  between  the  upper  portion  of 
the  testis  and  the  globus  major,, is  a  remnant  of  the  duct  of  Miiller. 

The  continuation  of  the  convoluted  canal  of  the  epididymis  is 
known  as  the  vas  deferens  ;  it  ascends  at  the  back  of  the  testicle 
as  part  of  the  spermatic  cord,  with  which  it  is  in  close  relation.  It 
enters    the    abdomen    through    the    internal    abdominal    ring    and 


INJURIES  AND  DISEASES  OF  THE  SCEOTUM  AND  TESTICLES.     619 


Fig.  195. 


descends  to  the  pelvis,  passing  forward  and  inward  across  the  ex- 
ternal iliac  vessels  and  around  the  deep  epigastric  artery.  On  reach- 
ing the  bladder  it  passes  downward  to  the  inner  side  of  the  ureter, 
and  at  its  base  is  joined  by  the  seminal  vesicles  to  form  the  ejacu- 
latory  duct.  The  vas  in  the  beginning  of  its  course  is  convoluted,  but 
for  the  greater  part  is  uniformly  cylindrical,  and  easily  recognizable 
from  the  rest  of  the  cord  by  its  dense  hard  feeling ;  when  it  reaches 
the  base  of  the  bladder  it  becomes  markedly  ampullated.  It  is  pro- 
vided with  an  external  cellular  coat,  a  muscular  coat,  and  an  inner 
mucous  membrane,  the  latter  covered  with  columnar  epithelium. 

The  seminal  vesicles  are  glandular  pouches  placed  between  the 
bladder  and  the  rectum.  They  are  pyramidal  in  shape,  with  their 
bases  directed  backward,  and,  although 
they  are  of  very  variable  size  and  shape 
in  different  individuals  and  often  on  the 
two  sides,  they  average  about  two  and  a 
half  inches  in  length  and  half  an  incli  in 
breadth.  They  lie  in  direct  contact 
with  the  base  of  the  bladder,  extend- 
ing from  the  entrance  of  the  ureter  to 
the  base  of  the  prostate  gland,  and 
are  separated  from  the  rectum  by  the 
recto-vesical  fascia.  (Fig.  195.)  Each 
seminal  vesicle  consists  of  an  irregular 
tortuous  tube,  giving  off  in  its  course 
several  blind  pouches,  which  are  con- 
nected by  fibrous  tissue.  This  tube 
becomes  narrowed  into  a  straight  duct, 
which  joins  the  vas  deferens  of  the 
corresponding  side,  to  form  the  ejacu- 
latory  duct. 

The  ejaculatory  ducts  are  about 
three-quarters  of  an  inch  long.  They 
pass  forward  and  upward  from  the 
base  of  the  prostate  along  the  side  of 
the  prostatic  sinus,  and  terminate  in  a 
slit  placed  at  the  lateral  margin  of  this 
sinus.  The  vesicles  and  ,ducts  are 
provided  with  an  external  fibro-cellular,  a  middle  muscular,  and  an 
internal  mucous  layer ;  the  epithelium  is  columnar. 

The  spermatic  cord  is  about  four  inches  in  length,  and  extends 
from  Ihe  internal  abdominal  ring  to  the  globus  minor  of  the  epididy- 


Dissection  showing  seminal  vesicles 
and  ampullae  of  the  vasa  in  relation  to 
the  bladder  and  prostate. 


620  GEi^ITO-UEISrARY  DISEASES   AXD   SYPHILIS. 

« 

mis.  It  is  made  up  of  the  vas  deferens,  or  excretory  duct  oi  tlie  testi- 
cle, tlie  spermatic  artery  from  the  aorta,  the  artery  of  the  vas  def- 
erens from  the  inferior  vesical,  the  cremasteric  artery  from  the  deep 
epigastric,  the  spermatic  veins,  the  spermatic  nerve  plexus,  branches 
of  the  iho-inguinal  and  genito-crural  nerves,  and  lymphatics.  These 
structures  are  bound  together  by  loose  fibrous  tissue,  and  are  in- 
vested by  the  fasciae  carried  down  by  the  testicle  in  its  descent. 
The  vas  deferens  lies  below  and  behind  the  larger  anterior  group  of 
veins  and  the  spermatic  artery.  The  veins  of  the  cord  called  the 
pampiniform  plexus  unite  into  a  single  trunk,  on  the  right  side  pass- 
ing into  the  inferior  vena  cava  and  on  the  left  side  into  the  left  renal 
vein.  The  artery  of  the  vas  is  in  direct  relation  with  it,  while  the 
spermatic  artery  follows  a  tortuous  course  through  the  cord.  The 
nerves  are  distributed  throughout  the  cord,  with  the  exception  of 
filaments  from  the  hypogastric  plexus,  which  invest  the  vas  in  a  rich 
net-work.  The  four  to  eight  lymphatic  vessels  empty  into  the  glands 
surrounding  the  lower  part  of  the  aorta,  and  one  gland  lying  over 
the  external  iliac  artery. 

DISEASES   OF   THE   SCROTUM. 

Deformities. — Congenital  deformities  of  the  scrotum  unaccom- 
panied by  malformation  of  the  penis  or  malposition  of  the  testicles 
are  practically  unknown.  With  hypospadia  and  hermaphroditism  the 
raphe  becomes  converted  into  a  distinct  cleft,  dividing  the  scrotum 
into  two  halves,  much  like  the  labia  majora.  When  there  is  an  un- 
descended testicle  the  scrotum  usually  does  not  develop  on  the  af- 
fected side,  thus  producing  some  asymmetry.  At  times  adhesions 
binding  together  the  scrotum  and  the  penis  are  noted  at  birth. 

Injuries  of  the  Scrotum. — Contusions  may  be  extensive  without 
involvement  of  the  testicles,  these  organs  readily  slipping  from  the 
direct  fine  of  pressure.  Such  injuries  are  followed  by  rapid  swelling, 
extensive  subcutaneous  blood  effusions,  and  intense  discoloration. 
They  should  be  treated  by  thorough  preliminary  cleansing  of  the  skin, 
rest,  pressure,  and  the  application  of  evaporating  lotions.  Under  such 
treatment  suppuration  does  not  take  place.  When  the  skin  is  not 
clean,  and  especially  when  it  becomes  abraded,  extensive  and  obstinate 
suppuration  may  occur. 

Wounds  of  the  scrotum  are  treated  upon  the  general  prin- 
ciples applicable  to  wounds  of  other  portions  of  the  body.  Hsemo- 
stasis  should  be  complete  before  closure,  since  the  vessels  are  with- 
out support,  and  if  not  secured  may  bleed  into  the  loose  cellular 
tissue,  forming  large  accumulations  of  blood. 


DISEASES   OF   THE   SCEOTUM.  621 

At  the  time  of  suture  the  borders  of  the  wound  must  be  so  approx- 
imated that  the  tendency  to  inversion  of  the  skin  will  be  overcome. 
Silk  or  horse-hair  forms  the  best  sewing  material,  Chinese  silkworm- 
gut  being  too  stiff  for  this  delicate  skin. 

After  closure  and  antiseptic  dressing  the  scrotum  should  be  sup- 
ported either  by  means  of  a  suspensory  bandage  or  by  a  crossed  of  the 
perineum  roller. 

CEdema  of  the  scrotum  may  be  an  expression  of  general  ana- 
sarca due  to  lesions  of  the  heart  and  kidneys,  in  which  case  it  is  usu- 
ally pronounced,  and  in  some  instances  first  calls  attention  to  the 
central  lesion,  or  it  may  be  due  to  inflammation  of  the  overlying  skin 
or  of  the  testicles,  local  interference  with  circulation,  as  from  lymph- 
adenitis of  the  groin,  infiltration  of  urine,  rupture  of  a  hydrocele,  or 
septic  infection.  Simple  oedema  sometimes  threatens  the  vitality  of 
the  part ;  in  this  case  tension  is  relieved  by  multiple  needle-punc- 
tures made  under  the  strictest  antiseptic  precautions.  Inflammatory 
oedema  is  treated  by  attacking  the  cause  of  inflammation, — evacuating 
the  extravasated  urine  by  incisions,  for  instance,  or  opening  abscesses. 

Emphyseina  may  be  due  to  entrance  of  air  into  the  loose  cellu- 
lar tissues  through  a  wound,  such  as  that  produced  by  the  trocar,  or 
to  the  escape  of  air  or  gas  from  a  hollow  viscus  remote  from  the  scro- 
tum ;  as,  for  instance,  when  the  stomach  and  intestines  are  opened, 
occasioning  general  emphysema.  More  commonly  it  is  due  to  gas,  the 
result  of  fermentation  and  putrefaction  in  loco,  and  this  in  a  measure 
is  an  index  to  the  extent  of  sloughing  or  gangrene  going  on  beneath 
the  surface. 

The  treatment  of  emphysema  when  it  is  simply  aerial  and  is  not 
a  symptom  of  extensive  tissue-destruction  should  be  conservative. 
When  it  is  due  to  the  gas  of  decomposition,  free  incisions  and  vigorous 
disinfection  are  required. 

The  cutaneous  affections  of  the  scrotum  are  practically  those 
of  other  skin  surfaces  of  the  body,  and  are  amenable  to  the  same 
treatment.  It  should  be  borne  in  mind,  however,  that  the  skin  of  the 
scrotum  is  extremely  sensitive  to  irritating  applications,  such  as  tinc- 
ture of  iodine,  which  if  painted  over  this  region  may  cause  intense 
pain  for  many  hours. 

There  are  certain  skin  eruptions  which  develop  on  the  scrotum 
with  great  frequency.  Among  these  are  erythema,  eczema,  pruritus, 
and  pediculosis.  More  rarely  molluscum  contagiosum,  sebaceous 
cysts,  pityriasis,  and  scabies  are  observed. 

Erythema  intertrigo  is  very  frequently  observed  in  children  and 
in  fat,  soft  men,  especially  those  who  are  rheumatic  in  tendency  or 


622  GENITO-URINAEY   DISEASES   AND  SYPHILIS. 

are  uncleanly  in  their  habits  and  who  are  given  to  exercise,  such  as 
walking,  which  occasions  friction  between  moist  surfaces. 

The  treatment  consists  in  thorough  cleanliness  and  the  interpo- 
sition of  a  layer  of  soft  mushn  or  lint  between  the  chafmg  surfaces, 
or,  better  still,  the  appKcation  of  a  suspensory  bandage,  made  of  thin 
gauze.  The  parts  are  bathed  in  weak  solutions  of  carboUc  acid  1  to 
200  and  hydrastis  canadensis  1  to  20,  after  which  they  are  carefully 
dried  and  dusted  with  finely  powdered  zinc  stearate  powder.  In 
some  cases  ointments  give  better  results.  One  of  the  best  is  that  of 
resorcin  two  per  cent,  made  up  with  lanolin  and  lard  equal  parts. 

Eczema  may  develop  in  healthy  persons,  though  it  is  more  fre- 
quently observed  in  association  with  the  gouty  or  rheumatic  diathesis, 
sometimes  in  connection  with  diabetes.  It  may  appear  in  almost  any 
of  its  various  forms,  is  extremely  obstinate,  and  causes  intense  itching 
and  burning.  There  are  frequently  concomitant  swelKng  of  the  whole 
scrotum,  deepening  of  the  transverse  rugae,  and  the  formation  of  raw 
surfaces  from  which  there  exudes  an  offensive  discharge. 

The  treatment  is  that  generally  apph cable  to  this  disease. 

Among  the  most  useful  prescriptions  are  the  following : 

R   Zinci  oxidi, 

Zinci  carbonat.,  aa  ^vi ; 

Glycerini ,  f^iv ; 

Liquor,  calcis,  f.^vi. 
M.     S. — Shake  well  before  applying. 

This  should  be  dabbed  on  for  four  or  five  minutes.  In  chronic 
cases  with  thickening  the  following  may  be  applied  (Bulkley) : 

Be   Picis  liquidse,  gii ; 
Potassse  causticse,  ji ; 
Aquae,  f^v. 

This  may  be  used  as  an  antipruritic,  diluted  with  twenty  to  thirty 
parts  of  water,  or  may  be  rubbed  directly  into  the  infiltration. 

An  excellent  powder  to  be  employed  during  the  day  is  the  following : 

R  Pulv.  amyli,  gvi ; 
Zinci  oxidi,  ^iss ; 
Pulv.  camphorse,  ^ss ; 

or 

R  Thymol,  gr.  ii ; 

Pulv.  zinci  stearat.,  ,^iv. 

Pruritus  is  most  frequently  observed  in  rheumatic  or  gouty  sub- 
jects. Though  often  associated  with  the  lesions  of  pediculi,  it  may 
develop  independently  of  these. 

The  treatment  must  be  in  the  main  systemic,  though  the  local 


DISEASES   OP   THE   SCEOTUM.  623 

antipruritic  applications,  such  as  thymol,  tannic  acid,  etc.,  are  service- 
able. Prolonged  hot  bathing  of  the  parts  is  useful.  In  severe  cases, 
with  almost  epileptiform  crises,  circumferential  incision  followed  by 
immediate  suture  may  be  serviceable. 

Pediculosis  ultimately  excites  intense  pruritus,  though  it  is  often 
not  detected  for  a  long  time.  Careful  examination  of  the  scrotum 
shows  the  parasites  at  once.  They  appear  as  minute  scabs,  most 
abundant  about  the  root  of  the  penis.    The  ova  are  found  on  the  hairs. 

Effective  remedies  are  an  ointment  of  twenty  per  cent,  oleate  of 
mercury  one  part,  cosmoline  two  parts,  or  of  mercurial  ointment  one 
part,  cosmoline  three  parts,  rubbed  into  the  scrotum  every  night.  The 
excess  should  be  wiped  off  with  a  soft  towel  before  retiring,  and  the 
whole  region  washed  with  soap  and  hot  water  the  next  morning. 

Tincture  of  cocculus  indicus  apphed  freely  after  a  warm  bath  and 
allowed  to  dry  on  the  part  is  more  cleanly  and  efficacious. 

MoLLuscuM  coNTAGiosuM,  obscrved  mostly  in  children,  particularly 
affects  the  scrotum.  The  lesions  are  small,  waxy,  almost  spherical 
tumors  or  cysts,  in  the  superficial  layers  of  the  skin.  They  are  sessile, 
but  may  become  pedunculated  when  they  have  existed  for  a  consider- 
able time  without  softening.  At  first  smooth  and  round,  they  become 
umbilicated,  exhibiting  a  small  black  spot  in  the  centre  of  the  depres- 
sion, which  indicates  the  opening  into  the  follicle.  They  grow  slowly, 
and  occasion  no  pain  unless  complicated  by  inflammation. 

They  may  disappear  spontaneously,  but  should  be  removed,  since 
they  are  contagious.  The  contents  of  the  cyst  may  be  squeezed  out 
and  the  walls  touched  with  pure  carbolic  acid.  Pedunculated  growths 
should  be  snipped  off  and  their  bases  cauterized. 

Steatomata  or  sebaceous  cysts  have  not  the  waxy  appearance  of 
molluscum,  nor  do  they  appear  in  childhood.  They  are  usually  sin- 
gle, but  may  be  multiple.  They  are  soft  and  doughy  in  consistence, 
and  when  attacked  by  inflammation  break  down  and  suppurate. 
They  sometimes  attain  the  size  of  a  hen's  egg.  The  thin  overlying 
skin  becomes  adherent  in  inflammatory  cases.  Incision  followed  by 
removal  of  the  entire  sac  is  the  only  effective  treatment. 

Gangrene  of  the  Scrotum. — This  affection,  extremely  rare, 
except  as  a  complication  of  rupture  of  the  urethra  or  as  a  sequel  of 
extensive  traumatism,  has  been  attributed,  when  it  follows  inflam- 
mation of  the  inguinal  glands  or  operation  on  these  structures,  to  re- 
flected nerve  irritation.  It  is  more  probable  that  gangrene  developing 
apparently  spontaneously,  or,  as  in  the  case  contributed  by  Bungner, 
following  inguinal  adenitis  in  the  course  of  grippe,  is  due  to  infection 
with  the  ordinary  pus  microbes. 


624  GENITO-XJEINAEY   DISEASES   AND   SYPHILIS. 

Among  the  causes  of  this  condition  are  included  urinary  infiltration, 
erysipelas,  thrombosis,  embolism,  and  incidentally  influenza,  typhus 
and  other  fevers,  syphilis,  gonorrhoea,  diabetes,  prostatic  disease, 
pediculi  pubis,  ergotism,  traumatism  (faulty  punctures  and  injections), 
and  frost-bite. 

Even  though  the  testicles  be  completely  denuded,  they  v^^ill  ulti- 
mately be  covered  by  granulation-tissue  and  their  function  will  be 
preserved. 

Treatment. — Scrotal  gangrene  should  be  treated  by  hot  antiseptic 
fomentations  until  the  sloughs  separate.  The  testicle  should  then  be 
covered  as  completely  as  possible  by  suturing  the  remaining  healthy 
skin,  the  wound  being  dressed  daily  until  complete  healing,  with  gauze 
wrung  out  of  1  to  10,000  bichloride  solution  or  other  antiseptic  lotion. 
When  due  to  urinary  infiltration — the  usual  cause — free  incisions,  and 
direct  drainage  from  the  point  of  urethral  rupture  are  indicated. 

Elephantiasis,  endemic  in  certain  countries,  is  rare  in  the  United 
States.  It  is  generally  supposed  to  be  due  to  the  stoppage  of  lymph- 
channels  by  the  ova  of  the  filaria  sanguinis  hominis,  but  in  this  country 
it  has  been  observed  in  cases  in  which  the  parasite  was  not  present 
in  the  blood,  and  the  obstruction  to  the  flow  of  lymph  could  be  ac- 
counted for  only  by  some  preceding  inflammatory  condition,  such  as 
recurrent  attacks  of  erysipelas  or  dermatitis,  or  cicatrization  following 
syphilitic  lesions  or  excision  of  the  inguinal  glands. 

Prunner  states  that  the  disease  always  begins  in  the  form  of  a 
hard  kernel  under  the  skin,  usually  at  the  bottom  of  the  left  side  of 
the  scrotum.  This  spreads  in  all  directions,  forming  a  difl'use,  hard, 
thick,  wrinkled  skin  tumefaction.  The  tumor  is  pyriform,  and  the 
rough,  often  warty,  skin  covering  it  is  likely  to  become  excoriated  from 
the  irritation  of  the  urine.  The  growth  may  attain  an  enormous  size, 
weighing  as  much  as  two  hundred  pounds.  It  is  commonly  associated 
with  some  degree  of  elephantiasis  of  the  skin  of  the  lower  extremities. 
The  testicles  and  penis,  however,  remain  unaffected.     (Fig.  196.) 

Treatment. — In  the  early  stages  galvanism  and  the  internal  admin- 
istration of  potassium  iodide  may  be  serviceable.  When  the  tumor 
attains  such  size  as  to  be  inconvenient  from  its  weight,  complete 
excision  of  all  the  diseased  tissues  is  indicated.  This  operation  is 
usually  bloody,  many  vessels  requiring  ligation.  The  best  means 
of  checking  hemorrhage  during  removal  is  to  transfix  the  tumor  at  its 
base  with  long  pins,  and  to  apply  behind  these  transfixing  pins,  the 
elastic  ligature.  The  fact  that  hernia  frequently  complicates  this  affec- 
tion must  be  borne  in  mind  in  applying  these  transfixing  pins  and 
securing- the  elastic  band.     The  penis  and  testicles  are  first  freed,  then 


DISEASES   OF   THE   SCKOTUM. 


625 


all  the  diseased  tissue  is  cut  away.  Even  though  the  testicles  are 
entirely  denuded,  this  need  not  occasion  anxiety,  since  they  will  be 
covered  by  granulation-tissue. 


Fig.  196. 


7 


Elephantiasis  of  the  penis  and  scrotum,  showing  the  result  of  operation. 

Tumors  of  the  Scrotum. — Epithelioma. — Aside  from  sebaceous 
cysts,  epithelioma  is  the  most  frequent  form  of  new  growth  observed 
upon  the  scrotum.  It  is  called  "  chimney-sweepers'  cancer,"  because 
it  formerly  attacked  by  preference  people  engaged  in  this  work.  In 
recent  years  the  method  of  cleaning  chimneys  has  changed,  and  the 
name  is  no  longer  applicable. 

It  begins  as  an  indurated  wart,  which  becomes  excoriated  and 
scabby  on  its  surface  ;  this  wart  is  shortly  transformed  into  an  ulcer, 
which  is  characterized  by  hard,  raised  edges,  uneven  surface,  un- 
healthy granulations,  and  the  exudation  of  ichorous  pus.     It  is  some- 

40 


626 


GENITO-XJEINAEY   DISEASES   AiND   SYPHILIS. 


times  extremely  painful,  and*  steadily  extends,  ultimately  involving  the 
inguinal  lymphatic  glands,  which  soften  and  ulcerate.  It  is  stated 
that  workers  in  coal-tar  are  especially  hable  to  this  form  of  disease. 

Treatment. — The  treatment  consists  in  the  removal  of  the  indu- 
rated tissues  by  an  incision  carried  wide  of  the  diseased  area.  Any 
enlarged  lymph-glands  should  be  removed  at  the  same  time.  Thus 
treated  early  in  the  course  of  the  affection  the  prognosis  is  favorable. 

Fatty  tumors  are  at  times  observed  ;  they  are  of  importance  be- 
cause of  their  intimate  connection  with  the  testicle.  Diagnosis  is 
rarely  possible  without  exploratory  incision,  because,  on  palpation, 
they  feel  almost  precisely  as  does  an  irreducible  omental  hernia. 
Excision  is  the  only  treatment. 

Fibromata  are  rarely  observed.  They  are  freely  movable  under 
the  skin.  They  should  be  removed  as  soon  as  discovered,  since  in 
their  development  they  may  form  adhesions  to  the  testicle,  which 
would  make  subsequent  operation  without  injury  to  this  gland  ex- 
tremely difficult.  These  fibrous  tumors  sometimes  recur  in  spite  of 
their  removal. 

GuMMATA,  ENCHONDROMATA,  osTEOMATA,  and  CYSTS  are  occasionally 
observed. 

ANOMALIES   OF   THE   TESTICLE. 
Excess. 


Anomalies  of 
development. 


In  number. 


In  size. 


Anomalies  of  migration. 


Deficiency. 

Excess. 
Deficiency. 


Testicle  undescended.     \ 


^  Testicle  descended. 


Polyorchism. 
Absence,  anorchism. 
Fusion,  synorchism. 
Hypertrophy. 
Arrested  development. 
Lying  in  some  part  of 

the  normal  course. 
Lying   outside   of  the 

normal  course. 
Inversion. 
(Monod  and  Terrillon.) 


Anomalies  of  Number. — 1.  Polyorchism. — With  the  exception 
of  the  case  reported  by  Blasius,  there  seems  to  be  no  well-authenti- 
cated record  of  supernumerary  testis.  Cases  are  frequently  encoun- 
tered in  which  careful  examination  shows  the  existence  of  a  body 
which  in  size,  shape,  and  position  corresponds  closely  to  a  third  tes- 
ticle ;  even  the  testicular  sensation — i.e.,  sickening  pain  on  pressure — 
may  be  present.  When  such  cases  have  been  subject  to  operation, 
or  when  an  opportunity  has  been  given  for  post-mortem  examina- 
tion, these  apparently  supernumerary  testes  have  been  proved  to  be 
encysted  hydroceles,  epiploceles,  fibromata,  or  other  comparatively 
common  pathological  conditions. 


DISEASES  OF  THE  TESTICLE.  ^£7 

2.  Anorchism. — This  deformity  may  be  unilateral  (monorchism)  or 
bilateral.  It  is  usually  unilateral,  and  the  epididymis  and  scrotal  por- 
tion of  the  vas  are  also  absent.  The  pelvic  portion  of  the  vas  and 
the  seminal  vesicles  are  ordinarily  present,  though  cases  are  recorded 
shov^ing  that  even  these  portions  of  the  genital  tract  may  be  wanting. 
The  testicle  may  be  present,  but  the  epididymis  or  vas  or  both  these 
structures  may  be  absent.  Bilateral  anorchism  is  accompanied  by 
The  testicle  may  be  present,  but  the  epididymis  or  vas  or  both  these 
structures  may  be  absent.  Bilateral  anorchism  is  accompanied  by 
absence  or  incomplete  development  of  the  scrotum,  a  rudimentary 
condition  of  the  external  genitalia,  impotence,  sterility,  and  the  physical 
and  mental  attributes  of  eunuchism. 

Diagnosis. — It  is  not  justifiable  to  infer  that  a  testicle  is  absent 
because  it  is  not  found  in  the  scrotum  or  the  inguinal  canal.  Indeed, 
a  positive  diagnosis  of  unilateral  anorchism  must  be  based  upon  the 
results  of  post-mortem  examination,  since  the  testis  may  be  retained 
in  the  abdominal  cavity.  A  distinction  betv^een  bilateral  retention  and 
anorchism  can  be  made  by  the  rudimentary  condition  of  the  penis  when 
the  testicles  are  absent,  and  by  the  later  development  of  eunuchism. 

Treatment. — Unilateral  anorchism  gives  rise  to  no  symptoms,  since 
one  testis,  if  it  remains  healthy,  is  competent  to  perform  the  functions 
of  both.  Bilateral  anorchism  would  seem  to  be  beyond  help.  Modern 
research  in  other  lines  of  work,  however,  suggests  the  possibility  of 
so  modifying  the  course  of  development  that,  though  potency  and 
fertility  cannot  be  expected,  the  physical  and  mental  characteristics 
of  the  male  may  be  preserved.  While  the  removal  of  either  testicles 
or  ovaries  in  early  hfe  usually  changes  profoundly  all  the  character- 
istics, physical  and  mental,  of  the  individual,  there  is  abundant  evi- 
dence that  the  testicles  may  lose  or  may  never  have  had  the  sperm- 
producing  power  and  still  possess  the  quality  which  enables  them  to 
hold  the  organism  in  its  normal  groove  and  to  invest  it  with  the  other 
attributes  of  masculinity.  When  testes  fail  to  descend,  as  a  rule,  they 
are  incapable  of  producing  spermatozoa.  In  spite  of  this  imperfec- 
tion of  the  organs,  the  external  bodily  characteristics  of  the  male  are 
acquired.  It  is  obvious  that  the  testicle,  in  addition  to  producing 
spermatozoa,  elaborates  an  internal  secretion  which  profoundly  affects 
general  nutrition.     (Griffiths.) 

It  is  possible  that  the  function  of  the  testicles  which  relates  to  the 
preservation  of  masculinity,  as  distinguished  from  the  function  of  re- 
production, may  be  exerted  through  a  definite  substance  which  has 
distinct  physiological  properties  of  its  own,  manifest  to  some  extent 
whenever  it  is  introduced  into  the  system. 

It  therefore  seems  reasonable  to  hope  that  testicular  injections  may 
exert  a  powerful  influence  on  the  general  development  of  bilateral  an- 


628  GENITO-UKINART  DISEASES  AND   SYPHILIS. 

orchids.  These  injections  should  be  instituted  at  an  early  age,  cer- 
tainly before  puberty,  and  should  be  continued  for  many  years.  A 
trial  of  this  method  has  never  been  made :  hence  the  dosage,  the 
number  of  repetitions,  and  the  period  of  time  over  which  treatment 
should  extend  cannot  be  formulated.  It  has  merely  the  merit  of 
being  the  only  treatment  thus  far  proposed. 

Anomalies  in  Size. — Hypertrophy. — In  common  with  all  the 
genital  organs,  the  normal  testicles  vary  greatly  in  size  and  without 
any  definite  relation  to  the  general  physical  development.  It  is, 
therefore,  difficult  to  determine  what  degree  of  growth  indicates  a 
departure  from  the  normal.  In  cases  where  one  testicle  has  been 
removed  or  has  become  atrophied,  the  remaining  gland  may  show  so 
marked  an  overgrowth  as  to  be  properly  considered  hypertrophied. 
This  is  particularly  hkely  to  occur  when  there  is  congenital  atrophy 
or  unilateral  ectopy.  The  destruction  of  the  testicle  by  inflammation, 
unless  this  occurs  in  early  life,  is  not  commonly  followed  by  enlarge- 
ment of  the  other  gland. 

Atrophy. — The  wasting  which  follows  acute  or  chronic  inflamma- 
tion cannot  properly  be  considered  a  congenital  malformation,  even 
though  this  atrophic  process  takes  place  in  early  infancy.  True  atro- 
phy is  nearly  always  observed  in  cases  of  non-descent  and  ectopy. 
Even  when  the  position  of  the  organ  is  perfect  one  or  both  testes  may 
remain  puerile.  It  is  a  matter  of  clinical  observation  that  these  puerile 
testes  may  attain  full  development  as  a  result  of  physiological  activity. 

Synorchism,  or  fusion  of  the  testicles,  is  an  extremely  rare  condi- 
tion. It  seems  to  have  been  found  only  in  foetal  life.  The  diagnosis 
of  the  condition  is  dependent  upon  the  finding  of  two  cords. 

Treatment. — Hypertrophy  calls  for  no  treatment,  since  it  is  com- 
pensatory and  is  dependent  upon  increased  physiological  activity.  It 
is  probable  that  a  gland  thus  enlarged  is  more  vulnerable  than  one  of 
normal  size  :  hence  it  is  desirable  to  support  it  by  a  suspensory  bandage 
if  the  scrotum  is  relaxed,  and  to  caution  the  patient  as  to  the  special 
danger  incident  to  urethritis. 

The  treatment  of  imperfect  development  of  the  testes  promises 
little.  There  is,  however,  sufficient  clinical  evidence  to  prove  that 
persistent,  long-continued  treatment  may  be  followed  by  gratifying  re- 
sults. The  stimulating  influence  of  massage  regularly  administered 
should  be  borne  in  mind,  and  the  effect  which  physiological  activity 
has  upon  growth  and  nutrition  should  be  considered  in  advising  such 
patients  and  in  predicting  as  to  their  future. 

The  transplantation  of  an  undescended  testicle  has  been  followed 
by  rapid"  increase  in  size. 


DISEASES  OF   THE   TESTICLE.  629 

Anomalies  in  Migration. — The  testicle  may  be  arrested  in  its 
transit  from  below  the  kidney  to  the  bottom  of  the  scrotum  at  any 
portion  of  its  course.  It  may  depart  from  its  regular  path,  taking  an 
aberrant  course,  or,  having  descended  normally,  it  may  assume  a 
faulty  position  in  the  scrotum. 

Arrest  of  Passage  in  the  Normal  Course. — The  testicle  may  be 
arrested  in  the  abdominal  cavity  or  in  the  inguinal  canal,  or  may  not 
fully  descend  into  the  scrotum. 

Abdominal  retention,  or  cryptorchism,  may  be  unilateral  or  bilat- 
eral. The  testicle  may  be  found  close  to  the  posterior  abdominal 
wall  in  relation  to  the  lower  border  of  the  kidney,  it  may  be  pro- 
vided with  a  long  mesorchium  allowing  it  to  move  freely  in  the 
abdominal  cavity,  or  it  may  lie  in  the  iliac  fossa  close  to  the  internal 
ring. 

Griffiths,  in  an  experimental  investigation  on  dogs,  found  that 
although  the  abdominal  testicle  develops  to  the  time  of  puberty,  it 
never  produces  spermatozoa.  When  the  testes  of  grown  dogs  were 
placed  in  the  abdominal  cavity  they  atrophied  and  no  longer  produced 
spermatozoa. 

In  inguinal  retention  the  testicle  may  be  arrested  at  the  internal 
ring,  in  the  inguinal  canal,  or  at  the  external  ring,  and  until  it  becomes 
adherent  by  inflammation  it  is  usually  extremely  mobile. 

This  variety  is  most  important  because  of  its  frequency,  because 
from  its  exposed  position  the  testicle  is  subject  to  irritation  and  injury, 
and,  finally,  because  it  is  liable  to  be  mistaken  for  hernia. 

In  incomplete  scrotal  descent  (cruro-scrotal  retention)  the  testicle 
Ues  outside  of  the  inguinal  canal,  but  fails  to  descend  completely,  and 
is  found  in  the  fold  between  the  scrotum  and  the  thigh,  at  varying 
distances  from  the  ring. 

When  the  testicle  takes  an  aberrant  course  (ectopy)  it  may  be  found 
beneath  the  skin  of  the  abdominal  wall  at  a  variable  distance  from  the 
external  abdominal  ring,  in  the  crural  region,  or  in  the  perineum. 

In  perineal  ectopy  the  testicle  is  found  as  a  distinct  ovoid  tumor, 
lying  to  one  side  of  the  central  raphe  and  in  front  of  the  anus.  The 
cord  can  of  I  en  be  traced  from  this  tumor  to  the  external  abdominal 
ring,  and  the  overlying  skin  sometimes  presents  the  peculiarities  of  the 
scrotum,  the  corresponding  side  of  this  sac  being  generally  atrophied. 
It  is  easily  seen  that  a  testis  thus  placed  can  scarcely  escape  frequent 
injury,  and  inflammation  and  destruction  of  secreting  structure. 

In  femoral  ectopy  the  testicle  occupies  the  position  of  a  complete 
femoral  hernia,  though  Curling  notes  a  case  in  which  the  gland  was 
three  inches  below  Poupart's  ligament  and  behind  the  femoral  vein, 


^30  GENITO-URINARY   DISEASES   A^S'D   SYPHILIS. 

with    the    cord    encircling  this  vessel.     The  testicle  passes  beneath 
Poupart's  ligament  and  through  the  saphenous  opening. 

Curling,  after  considering  the  etiology  of  non-descent,  maintains 
that  in  some  cases  retention  is  due  to  the  small  size  of  the  external 
ring.  Other  causes  which  may  be  operative  are  the  application  of  a 
tight-fitting  truss  before  the  descent  of  the  testes,  shortness  of  the  ves- 
sels of  the  cord,  and  a  long  mesorchium  preventing  the  testicle  from 
entering  the  canal. 

The  irregular  development  of  the  gubernaculum  will  explain  cruro- 
femoral  and  peno-pubic  ectopy.  The  lower  attachments  of  this  fibro- 
muscular  structure  are  Poupart's  ligament  in  the  course  of  the  inguinal 
canal  (Curling),  the  lower  part  of  the  scrotum,  and  the  pubic  bone. 
There  are  also  fibres  passing  to  the  region  of  the  saphenous  opening. 
Relative  over-development  of  certain  of  these  bands  may  draw  the 
testicle  into  a  faulty  position. 

As  a  rule,  misplaced  testicles  are  undersized,  though  apparently 
healthy  until  they  have  been  subjected  to  repeated  attacks  of  inflam- 
maticn.  When  removed  from  the  adult  and  examined  they  show 
degeneration  and  atrophy  of  the  secreting  structure.  This,  however, 
is  inflammatory  in  nature  and  not  inseparably  connected  with  under- 
development. Curiing  holds  that  undescended  testicles  are  func- 
tionless  so  far  as  reproduction  is  concerned,  and  hence  that  bilateral 
retention  causes  sterility,  though  not  necessarily  impotence. 

Monod  and  Arthaud  have  attempted  to  demonstrate,  on  the  other 
hand,  that  a  retained  testicle  may  secrete  healthy  semen  and  show  no 
degenerative  changes  on  section,  such  alterations  being  due  to  repeated 
inflammations  to  which  the  gland  is  necessarily  subject  from  its  faulty 
position.  In  one  undescended  testicle  which  we  removed  from  a  man 
forty-five  years  old  in  the  course  of  a  radical  operation  for  strangu- 
lated hernia,  microscopic  section  of  the  gland,  which  was  about  the 
size  of  that  normally  found  in  a  child  of  twelve,  showed  it  to  be  fully 
functional,  although  it  had  been  subject  to  a  number  of  inflammatory 
attacks. 

Incomplete  transit  is  most  commonly  manifested  in  the  form  of 
inguinal  retention ;  the  aberrant  transit,  in  the  form  •  of  perineal 
ectopy. 

Complications  of  Misplaced  Testicles. — Hernia,  inflammation,  and 
malignant  degeneration  are  the  serious  compHcations  of  abnormally 
placed  testes. 

Hernia  is  an  extremely  common  complication,  and  is  usually  of  the 
congenital  variety,— i.e.,  there  is  a  direct  communication  from  the  ab- 
dominal cavity  to  the  testis,  the  funicular  portion  of  the  peritoneal  sac 


DISEASES   OF   THE   TESTICLE.  63X 

not  having  become  obliterated.  The  funicular  form  is  also  found  ;  in 
this  the  testicle  is  shut  off,  but  the  peritoneal  pouch  which  descends 
with  the  cord  still  remains  patulous.  Hernia  is  a  grave  complication 
of  misplaced  testis,  since  it  is  especially  liable  to  sudden  and  complete 
strangulation.  Because  of  the  presence  of  the  testicle  a  retaining  truss 
can  rarely  be  worn. 

Inflammation  frequently  attacks  a  misplaced  testicle,  particularly 
the  inguinal  form,  since  the  imperfectly  developed  gland  seems  to  be 
especially  vulnerable.  Inflammation  may  be  due  to  traumatism  or 
to  extension  of  infection  from  the  posterior  urethra.  Traumatic  in- 
flammation may  be  caused  by  a  blow  or  by  sudden  contraction  of 
the  abdominal  muscles,  which  pinch  the  testicle  in  its  already  too 
straitened  environment.  It  is  probable  that  the  misplaced  testicle 
is  not  immune  against  the  infection  which  develops  in  the  course  of 
mumps,  typhoid  fever,  and  other  diseases  which  are  often  compli- 
cated by  orchitis.  Jacobson  states  that  syphilis  and  tuberculosis  have 
not  been  observed  to  attack  such  testes. 

Malignant  Degeneration. — The  comparative  frequency  with  which 
malignant  disease  attacks  misplaced  testicles  is  generally  recognized. 
The  predisposition  is  probably  due  to  the  frequent  inflammatory 
attacks  to  which  the  gland  is  subjected.  The  growths  found  are 
usually  sarcoma  and  encephaloid  carcinoma. 

Symptoms. — Symptoms  of  anomalies  of  migration  of  the  testis  are 
wanting.  Until  the  onset  of  complications  there  will  be  no  complaint, 
except  perhaps  slight  transitory  testicular  pain,  caused  by  sudden 
violent  muscular  exertion  or  by  blows  or  jars  in  the  region  of  the 
misplaced  gland.  The  comphcations  are,  however,  extremely  im- 
portant, since  some  of  them  directly  threaten  life. 

The  symptoms  of  orchitis  are  practically  the  same  whether  the 
testis  is  descended  or  undescended.  There  are  sickening,  even  ago- 
nizing pain,  radiating  into  the  scrotum  and  down  the  thighs,  exquisite 
tenderness,  and  often  abdominal  reflexes  so  pronounced  as  strongly  to 
suggest  acute  peritonitis.  The  constitutional  symptoms  are  propor- 
tionate in  severity  to  the  degree  of  inflammation,  and  are  most  pro- 
nounced when  the  testicle  becomes  gangrenous,  either  from  the  vio- 
lence of  traumatism  or  inflammation,  or  from  torsion ;  this  accident 
seems  to  be  especially  common  in  cases  of  inguinal  retention. 

Hydrocele  and  hsematocele  frequently  complicate  inflammation. 
Hydrocele  may  be  of  the  congenital  variety, — that  is,  reducible  into 
the  peritoneal  cavity  ;  sooner  or  later  it  becomes  distinctly  hmited. 

Exceptionally,  the  testicular  inflammation  may  cause  general  peri- 
tonitis ;  Curling  has  reported  one  death  from  this  complication.    Very 


632  GENITO-UKINAEY  DISEASES   AND   SYPHILIS. 

commonly  abdominal  symptoms  develop  so  suddenly  and  violently 
that  they  closely  simulate  those  dependent  upon  the  presence  of  a 
strangulated  hernia.  There  may  be  tympany,  tenderness,  consti- 
pation, and  vomiting  so  persistent  as  to  have  a  markedly  stercoraceous 
character.  The  distinction  between  orchi-epididymitis  attacking  an 
undescended  testicle  and  strangulated  inguinal  hernia  is  often  ex- 
tremely difficult  to  make. 

Hernia  when  it  complicates  undescended  testicle  is  manifested  by 
the  usual  symptoms,  but  will  often  exhibit  the  peculiarity  of  not  being 
amenable  to  treatment  by  truss,  pressure  of  the  pad  producing  so 
much  pain  that  it  cannot  be  borne.  The  hernia  may  pass  beyond  the 
testis,  reaching  the  scrotum  ;  sometimes  it  pushes  the  testis  in  front  of 
it,  thus  curing  the  displacement.  When  the  hernia  becomes  strangu- 
lated the  symptoms  are  not  different  from  those  commonly  observed 
in  strangulated  hernia. 

Malignant  degeneration  exhibits  the  symptoms  which  characterize 
cancer  of  the  normally  placed  testis,  except  the  location  of  the  tumor. 
The  testicle  steadily  and  rapidly  enlarges,  becomes  irregular  in  shape, 
often  cystic,  painful,  and  involves  the  anatomically  related  glands. 
The  skin  is  discolored  and  marked  by  large  veins.  In  cases  of 
abdominal  retention  the  diagnosis  cannot,  of  course,  be  formulated 
until  the  tumor  has  reached  considerable  size,  since  till  then  it  is  not 
palpable.  A  persistent,  steadily  increasing,  obstinate  pain  should  in 
the  case  of  abdominal  retention  suggest  the  possibility  of  malignant 
infiltration.  In  the  late  course  of  malignant  disease  the  diagnosis 
cannot  for  a  moment  be  in  doubt,  since  the  large  palpable  tumor  and 
glandular  involvement  are  characteristic. 

Diagnosis. — The  diagnosis  of  misplaced  testicle  is  based  on  (1) 
the  absence  of  the  gland  from  its  normal  position ;  in  infants  and 
young  children  the  testes  may  be  extremely  small,  sometimes  not 
much  larger  than  a  kidney-bean,  and  because  of  their  great  mobilit)'^ 
may  be  hard  to  find  ;  (2)  the  detection  in  the  abnormal  position  of  a 
smooth,  usually  movable  tumor,  shaped  like  a  normal  testicle,  but 
smaller,  and  yielding  on  pressure  the  testicular  sensation  ;  in  making 
this  examination,  unless  the  testis  is  found,  the  patient  should  be  in- 
structed to  cough  and  strain,  since  thus  there  may  be  brought  within 
reach  an  undescended  testis  lying  high  up  in  the  inguinal  canal ;  (3) 
atrophy  of  the  scrotum  of  the  side  corresponding  to  the  misplace- 
ment. In  cases  of  abdominal  retention  the  only  signs  are  absence  of 
the  testis  from  the  normal  position  and  atrophy  of  the  scrotum. 

Prognosis. — The  prognosis  of  imperfect  descent  of  testicles  is  fairly 
good  in  young  children,  since  ultimately  the  gland  is  likely  to  reach 


DISEASES   OF   THE   TESTICLE.  633 

its  proper  position.  This  is  not  true  of  ectopy.  In  case  the  gland 
does  not  descend  before  birth,  it  commonly  does  so  shortly  after- 
wards, and  no  anxiety  should  be  experienced  for  several  weeks,  espe- 
cially if  the  testicles  can  be  felt  in  the  inguinal  region  and  the  scrotum 
is  properly  developed.  If  the  descent  does  not  take  place  during  in- 
fancy or  childhood,  there  is  still  a  chance  that  it  may  occur  about  the 
period  of  puberty,  sometimes  as  the  result  of  violent  straining  effort. 
The  gradual  descent  is  often  complicated  by  hernia. 

As  a  rule,  a  testicle  which  has  shown  no  signs  of  descent  by  the 
sixth  year  will  retain  its  faulty  position  unless  subjected  to  surgical 
treatment. 

Treatment. — It  is  generally  conceded  that  intra-abdominal  ectopy 
cannot  be  benefited  by  surgical  intervention.  The  vascular  and 
nervous  attachments  of  the  gland  are  too  short  to  allow  of  its  being 
drawn  into  its  proper  position.  A  partially  successful  effort,  bringing 
it  into  the  inguinal  canal,  would  be  worse  than  useless.  Guelliot, 
however,  reports  a  most  suggestive  case.  He  operated  for  bilateral 
abdominal  ectopy  :  one  testis  was  secured  in  the  scrotum  ;  two  years 
later  this  gland  was  well  developed,  and  the  boy,  then  eighteen  years 
old,  was  normal  in  regard  to  his  sexual  functions.  In  the  semen 
were  found  a  few  apparently  normal  spermatozoa.  While  it  is  prob- 
able that  patients  subject  to  bilateral  abdominal  retention  of  the  testi- 
cle will  be  sterile,  they  are  likely  to  suffer  from  no  inconvenience, 
since  the  gland  is  so  placed  as  to  be  protected  from  injury. 

Inguinal  retention  should  be  treated  conservatively  when  it  is 
observed  in  early  life.  The  gland  should  be  encouraged  to  descend 
to  its  normal  position  by  gentle  manipulation  with  the  fingers,  and 
should  be  kept  without  the  external  abdominal  ring  by  the  applica- 
tion of  a  pressure  bandage  or  a  truss,  in  case  this  can  be  so  appHed 
as  not  to  cause  pain. 

Persistence  in  this  treatment  is  justifiable  to  the  sixth  or  eighth 
year  if  the  testicle  in  the  mean  time  does  not  become  inflamed  or 
show  signs  of  atrophy.  After  the  sixth  year  the  operative  treat- 
ment may  be  considered,  but  it  should  be  remembered  that  sponta- 
neous descent  may  take  place  about  the  period  of  puberty ;  this  is, 
however,  not  the  rule.  Operation  is  especially  indicated  if  the  mal- 
formation is  bilateral,  if  the  testicle  has  been  subject  to  repeated 
attacks  of  inflammation,  or  if  from  its  position  and  its  chronically  in- 
flamed condition  it  prevents  proper  indulgence  in  active  sports. 

Since  one  of  the  reasons  for  operating  is  to  encourage  growth, 
this  should  be  undertaken  before  the  most  active  period  of  develop- 
ment.    The  ordinary  position  of  the  misplaced  testicle  is  just  within 


634  GENITO-UKINAEY   DISEASES  AND   SYPHILIS. 

the  external  ring ;  an  incision  sufficiently  large  to  expose  it  is  made 
directly  over  the  gland.  The  incision  divides  the  skin,  the  superficial 
fascia,  and  the  aponeurosis  of  the  external  obKque,  which  is  often 
very  thin.  The  testicle  is  then  carefully  examined,  to  see  that  it  is 
not  comphcated  by  hernia.  Should  this  be  present  and  should  the 
vaginal  tunic  communicate  with  the  peritoneal  cavity,  the  hernial  sac 
is  cut  across  just  above  the  testis,  and  the  distal  end  is  closed  with 
catgut  sutures,  thus  forming  a  closed  tunica  vaginalis.  The  proximal 
end  is  then  dissected  up  to  the  internal  ring  and  there  ligated.  After 
the  testicle  is  thoroughly  exposed,  the  cord  is  stretched  until  the  gland 
hangs  freely  beyond  the  external  abdominal  ring.  This  should  al- 
ways be  preceded  by  transverse  division  of  all  the  fibres  of  the 
cremaster  muscle  and  the  fibrous  envelope  of  the  cord,  leaving  only 
the  vas  with  its  vessels  and  nerves.  Incomplete  division  of  the 
muculo-fibrous  funicular  sheath  is  the  common  cause  of  failure. 

The  testicle  having  been  drawn  well  out  so  that  it  exhibits  no 
tendency  to  retract  within  the  inguinal  canal,  the  finger  is  thrust  from 
the  lower  corner  of  the  wound  into  the  scrotum,  tearing  a  way  through 
the  loose  areolar  tissue.  The  scrotum  is  then  invaginated  until  its 
inner  surface  appears  in  the  wound,  and  the  testis  is  fastened  to  it  by 
one  or  two  silk  or  chromicized  catgut  sutures,  which  include  the 
proper  tunic  of  the  lower  extremity  of  the  gland  and  epididymis  and 
the  deeper  layers  of  the  scrotal  skin.  The  aponeurosis  of  the  exter- 
nal oblique  is  then  closed  with  chromicized  catgut,  the  external  ring 
being  made  as  small  as  is  possible  without  interfering'  with  the  circu- 
lation of  the  cord.  The  cord  is  sutured  to  the  borders  of  the  ring 
and  the  wound  is  closed,  a  moderately  firm  compress  being  so  placed 
that  the  testicle  is  kept  in  its  normal  position. 

Ectopy  of  the  Testicle. — Debule  passes  the  testicle  through  an 
incision  in  the  scrotum  and  sutures  it  to  the  inner  upper  surface  of  the 
deep  fascia  of  the  thigh  exposed  by  cutting  through  the  skin  and  super- 
ficial fascia.  The  borders  of  the  scrotal  and  thigh  incision  are  sewed 
together  and  the  line  of  suture  is  protected  by  a  collodion  dressing. 
When  extreme  abduction  of  the  leg  no  longer  occasions  obvious  and 
perceptible  tension  upon  the  cord  the  testicle  is  released  from  its  false 
position,  placed  in  the  scrotum  and  the  two  skin  wounds  are  each 
separately  closed  by  suture. 

Jalaguier  reports  fifteen  operations  of  orchidopexy ;  fourteen  were 
successful.  He  advocates  the  operation  in  children  over  five  years, 
and  in  younger  children  when  the  undescended  testis  is  complicated 
by  painful  hernia. 

When  the  scrotal  sac  is  shallow  an  almost  transverse  incision  is 


DISEASES   OF   THE   TESTICLE.  g35 

made  directly  over  the  position  the  testicle  should  occupy.  After 
completion  of  the  operation  the  wound  is  sutured  at  right  angles  to 
its  original  course,  thus  providing  a  pouch  for  the  testis.  In  very 
young  children — i.e.,  those  who  cannot  be  prevented  from  wetting  the 
dressings — the  wound  should  be  thoroughly  protected  by  a  cotton 
collodion  dressing. 

Cruro-scrotal  retention  is  usually  amenable  to  manipulation  and 
the  application  of  a  truss  provided  with  a  water-pad  which  presses 
from  above  downward.  Should  the  testis  remain  tightly  apposed  to 
the  external  ring,  occasioning  pain  on  muscular  effort,  the  displace- 
ment should  be  cured  by  the  operation  indicated  for  the  rehef  of  an 
inguinal  retention. 

Perineal  ectopy  should  always  be  subjected  to  operation,  since 
from  its  position  the  testicle  is  exposed  to  frequent  injury.  The  advice 
is  usually  given  to  wait  until  the  third  or  fourth  year  of  life  before 
attempting  replacement,  mainly  because  after  that  time  there  is  less 
danger  of  infection  through  soiling  the  dressings.  We  believe  it  is 
well  to  follow  this  plan,  provided  the  testis  is  not  injured  by  the  exer- 
cises of  early  childhood,  such  as  walking,  running,  and  playing.  The 
wound  can,  however,  be  almost  perfectly  protected  by  the  application 
of  a  collodion  dressing. 

Operation  having  been  decided  upon,  the  testicle  is  pushed  as 
near  the  scrotum  as  possible,  and  an  inch  and  a  half  incision  is  made 
on  the  scrotal  side  of  the  testis  and  at  right  angles  to  the  raphe,  ex- 
posing the  cord ;  by  drawing  upon  this  structure  and  by  the  use  of 
retractors  the  testicle  can  be  exposed  and  the  fibrous  adhesions  bind- 
ing it  to  its  faulty  position  divided.  Through  the  cellular  tissue  a  way 
is  then  forced  to  the  bottom  of  the  scrotum ;  this  pouch  is  invagi- 
nated  into  the  wound,,  the  base  of  the  testis  and  the  epididymis  are 
secured  to  it  by  two  or  three  sutures,  and  the  perineal  wound  is 
sutured  at  right  angles  to  its  length,  thus  deepening  the  scrotal 
pouch. 

Pubic  and  crural  ectopy  are  so  rarely  found  that  their  treatment 
by  operative  procedures  has  not  been  formulated.  A  testicle  placed 
in  front  of  the  pubis  at  the  root  of  the  penis  should  be  transplanted 
into  the  scrotum  without  difficulty. 

In  crural  ectopy  the  testis  should  be  reduced  into  the  abdominal 
cavity,  together  with  the  hernia  which  usually  accompanies  it,  and 
should  be  retained  by  a  truss.  Failing  this,  a  protecting  truss  may 
be  applied.  If  the  testis  is  still  subject  to  repeated  attacks  of  inflam- 
mation, castration  is  generally  advised,  though  from  the  surgical  point 
of  view  there  seems  no  good  reason  why  the  testis  could  not  be 


636  GENITO-UEINAKY  DISEASES  AND  SYPHILIS. 

placed  in  its  proper  position  by  freeing  it  and  its  cord  and  dividing 
Poupart's  ligament. 

Operations  for  the  cure  of  undescended  or  ectopic  testicles  are 
advisable  particularly  in  infancy  and  childhood.  Later  in  life  these 
misplaced  testes  will  nearly  always  be  partially  degenerated  and  atro- 
phied in  consequence  of  the  repeated  inflammation  to  which  they  have 
been  subject.  The  secreting  substance  usually  disappears,  and  the 
testis  remains  an  organ  without  functional  activity,  but  vulnerable  and 
liable  to  malignant  degeneration.  Castration  is  therefore  advisable,  and 
is  particularly  indicated  because  the  condition  is  commonly  compli- 
cated by  hernia,  and  removal  of  the  testis  enables  the  surgeon  to 
close  completely  the  internal  and  external  ring  and  the  inguinal  canal, 
thus  insuring  against  recurrence  of  hernia.  When  the  patient  is  pos- 
sessed of  but  one  testis,  which  is  misplaced  or  ectopic,  even  though 
this  has  been  repeatedly  inflamed,  every  effort  should  be  made  to  pre- 
serve it  and  to  place  it  in  its  normal  position.  Routier,  finding  on 
operation  that  the  testicles  could  not  be  brought  into  the  scrotom, 
freed  them  and  left  them  in  the  abdomen,  giving  the  patient  entire 
relief  from  his  recurring  attacks  of  inflammation. 

Treatment  of  Complications  of  Misplaced  Testicle. — Inflammation. — 
The  general  indications  in  the  treatment  of  inflammation  in  an  un- 
descended or  ectopic  testis  are  those  appropriate  to  a  like  condition 
of  the  normally  placed  gland.  Rest  in  bed,  elevation  of  the  pelvis, 
moderate  purgation,  the  apphcation  of  heat  or  cold,  depending  upon 
the  preference  of  the  patient,  and  the  relief  of  pain  by  hypodermic 
injections,  represent  the  general  hne  of  treatment.  When  the  inflam- 
mation ranges  high  and  there  is  doubt  in  regard  to  diagnosis,  there 
should  be  no  hesitation  in  making  an  incision  and  exposing  the  gland, 
since  the  rehef  of  tension  thus  secured  is  immediately  followed  by 
marked  alleviation  of  pain.  When  the  testicle  is  subject  to  recurrent 
attacks  of  inflammation,  removal  of  the  gland  is  the  operation  of 
choice. 

Hernia. — When  ectopy  is  complicated  by  hernia,  and  the  latter 
exhibits  a  tendency  to  push  the  misplaced  testis  before  it,  thus  favor- 
ing its  descent,  no  retention  apparatus  should  be  applied  until  the 
gland  has  escaped  from  the  external  ring.  A  truss  should  then  be  so 
adjusted  that  it  will  keep  the  hernia  from  descending  and  push  the 
testis  still  farther  down.  Unfortunately,  cases  are  rare  in  which  the 
hernia  exhibits  this  tendency.  More  frecjuently  it  slips  beyond  the 
testicle,  escaping  through  the  external  abdominal  ring  before  the 
gland ;  a  truss  is  then  insupportable,  and  operation  offers  the  only 
prospect  of  cure.     If  the  patient  is  young  and  the  testicle  has  not 


DISEASES   OF   THE   TESTICLE.  637 

been  repeatedly  inflamed,  the  gland  is  brought  to  its  normal  position 
in  the  scrotum  and  the  hernia  is  radically  cured.  After  the  age  of 
puberty  it  is  usually  desirable  to  remove  the  testicle,  entirely  closing 
the  rings  and  canal. 

Malignant  growth  should  be  treated  by  early  and  complete  re- 
moval. When  the  testicle  is  intra-abdominal  this  form  of  interven- 
tion is  rarely  practicable  until  the  disease  has  become  so  well  devel- 
oped that  there  is  no  prospect  of  radical  cure,  since  diagnosis  cannot 
be  made  until  a  decided  tumor  develops.  In  inguinal  ectopy  enlarge- 
ment of  the  gland  may  be  detected  early.  Therefore  operative  inter- 
ference promises  better  results.  Whenever  an  undescended  testicle 
increases  in  size  without  inflammatory  phenomena,  operation  should 
be  performed  immediately.  The  removal  of  malignant  testicle  is 
usually  unattended  with  operative  difficulty. 

Torsion. — The  undescended  testicle  seems  to  be  particularly  sub- 
ject to  the  accident  of  strangulation  by  torsion.  When  symptoms  of  ■ 
extremely  severe  inflammation  develop  with  unusual  suddenness  and 
severity  and  without  obviously  sufficient  cause,  incision  and  exposure 
of  the  undescended  testis  are  indicated.  The  cord  may  be  untwisted 
or  the  testis  removed.  The  latter  course  is  desirable,  since  testes 
subject  to  torsion  are  liable  to  undergo  malignant  degeneration. 

Inversion  of  the  Testicle. — The  testicle,  though  it  descend  to 
the  bottom  of  the  scrotum,  may  assume  various  faulty  positions  termed 
inversions.  This  displacement  may  be  anterior,  horizontal,  or  lateral. 
The  horizontal  form  is  commonest.  The  testicle  may  be  rotated  com- 
pletely, the  epididymis  lying  in  front,  the  free  border  to  the  rear. 

No  treatment  is  indicated  in  these  cases,  displacement  being  im- 
portant mainly  when  surgical  intervention  is  required, — for  the  cure 
of  hydrocele,  for  instance.  With  this  present  in  the  case  of  anterior 
inversion,  the  testicle  and  epididymis  would  lie  in  front  and  not  be- 
hind the  fluid  contained  in  the  sac  of  the  vaginal  tunic :  hence  were 
a  trocar  introduced  at  the  customary  point  it  would  wound  both  the 
testicle  and  the  epididymis.  The  possibility  of  inversion  is  a  reason 
for  invariably  examining  hydrocele  by  transmitted  light  before  tapping. 
Careful  palpation,  when  the  sac-wall  is  thick  or  the  contents  are  turbid, 
will  usually  elicit  the  testicular  sensation,  suggesting  the  faulty  position 
of  the  gland. 

Monod  and  Terrillon  advise  that  in  tapping  cases  where  the  posi- 
tion of  the  testicle  remains  in  doubt,  the  puncture  should  be  made  on 
the  outer  side  of  the  scrotum  instead  of  in  front. 

Of  the  other  forms  of  inversion  fewer  cases  have  been  reported, 
nor  are  they  of  much  surgical  importance.     In  the  horizontal  variety 


638  GENITO-UKINAKY   DISEASES   A^D   SYPHILIS. 

the  long  axis  of  the  gland  lies  in  the  horizontal  position,  the  epididy- 
mis  looking  upward.  Lateral  inversion  is  a  modification  of  the  an- 
terior variety.  Reversion  of  the  testis  has  been  reported  by  a  few 
observers  ;  the  upper  end  of  the  gland  looks  downward. 

Luxation  of  the  Testicle.— The  testicles  may  be  displaced  by 
direct  traumatism  or  muscular  action.  The  ordinary  cause  of  this 
displacement  is  sudden  violent  contraction  of  the  cremaster  muscle  re- 
flexly  excited  in  the  course  of  a  severe  general  muscular  strain,  follow- 
ing violence  or  without  obvious  cause.  The  testis  may  be  fixed  in  the 
groin  external  to  the  ring  from  tonic  spasm  of  the  cremaster,  may  be 
lodged  in  the  inguinal  canal,  or  may  be  drawn  even  within  the  ab- 
dominal cavity;  it  is  generally  found  within  the  inguinal  canal.  It 
shortly  becomes  inflamed  and  is  subject  to  the  general  accidents 
already  considered  under  the  head  of  congenital  displacement. 

Tr-eatment. — The  treatment  of  luxated  testicle  is  prompt  replace- 
ment. This  usually  requires  the  administration  of  ether,  since  inflam- 
mation develops  rapidly  and  the  gland  becomes  excessively  tender. 
If  the  testicle  is  held  in  its  faulty  position  by  adhesions  or  tonic 
contraction  of  the  cremaster  muscle,  the  operation  for  incomplete 
descent  is  indicated,  the  cremasteric  fibres  being  cut  through  and  the 
testis  replaced  and  held  to  the  bottom  of  the  scrotum  by  sutures. 

Torsion  of  the  Testicle.— Torsion  or  axial  rotation  of  the  sper- 
matic cord  sufficiently  describes  the  nature  of  this  accident.  It  is  one 
of  sudden  development,  usually  affecting  the  cords  of  undescended 
testes,  though  by  no  means  confined  to  these.  The  cause  of  this  twist 
has  not  been  formulated ;  it  is  probably  dependent  upon  congenital 
malformation,  since  Owxn  has  pointed  out  that  a  testis  properly  placed 
in  the  scrotum  and  possessed  of  a  normal  mesorchium  cannot  be 
twisted.  The  twist  may  be  either  to  the  right  or  to  the  left,  and  in 
accordance  with  its  extent  and  the  degree  of  constriction  to  which 
the  vessels  are  subject  the  symptoms  are  slight  or  severe.  In  slight 
cases  the  epididymis  alone  becomes  infiltrated.  In  severe  cases  the 
entire  gland  with  the  epididymis  becomes  gangrenous,  exhibiting  ex- 
tensive blood  extravasations. 

Symptoms. — The  symptoms  of  torsion  are  those  of  epididymitis  or 
orchi-epididymitis.  They  occur  suddenly,  often  without  apparent 
cause  and  during  active  muscular  exertion.  When  the  rotation  is 
sufficient  to  produce  complete  strangulation  the  symptoms  are  violent 
and  rapidly  progressive.  In  cases  of  abdominal  or  inguinal  retention 
the  symptoms  may  be  marked  by  those  of  a  local  peritonitis.  The 
lesion  has  occurred  in  infants. 

Diagnosis. — A  positive  diagnosis  is  rarely  possible  without  direct : 


CONTUSIONS   AND   WOUNDS   OF    THE    TESTICLE.  639 

exploration  through  an  incision,  the  symptoms  suggesting  an  exces- 
sively acute  orchi-epididymitis  or  a  strangulated  hernia.  Since  torsion 
commonly  affects  an  undescended  testis, — this  is  often  complicated  by 
hernia, — the  differential  diagnosis  may  be  extremely  difficult.  The  in- 
guinal tumor  is  painful,  swollen,  sometimes  reddened  and  (Edematous, 
and  gives  no  impulse  on  coughing ;  it  develops  quite  suddenly  after 
exertion.  Vomiting  and  tympany  are  by  no  means  uncommon.  These 
symptoms  are  so  hke  those  of  strangulation — indeed,  are  so  indistin- 
guishable from  this  condition — that  immediate  exploratory  operation 
is  indicated. 

When  the  testis  occupies  a  normal  position  there  is  little  likelihood 
of  confounding  a  twist  of  the  cord  with  hernia  unless  the  latter  has 
been  a  previous  compKcation,  since  the  cord  can  be  felt  above  the 
swelling  and  the  inguinal  canal  is  free  from  hernial  sac  or  contents. 

The  diagnosis  of  torsion  will,  then,  depend  mainly  upon  the  sud- 
denness of  onset,  the  severity  of  symptoms,  and  the  absence  of  other 
sufficient  causes  for  acute  inflammation.  Moreover,  the  epididymis 
may  be  found  in  front  of  the  testis,  and  in  one  case  a  nodulation 
corresponding  to  the  twist  was  felt. 

Prognosis. — If  untreated,  the  testicle  will  either  atrophy  or  become 
gangrenous  ;  gangrene  depending  probably  upon  hsematogenous  infec- 
tion of  the  devitalized  area. 

Treatment. — Reduction  should  be  effected  by  manipulation  or  by 
operation.  Rotation  must  be  made  in  the  direction  opposite  to  that 
which  is  causative  of  pain. 

When  the  patient  is  not  seen  early,  and  when  the  inflammatory 
phenomena  are  pronounced,  incision  is  indicated.  This  should  expose 
the  testicle  and  cord.  If  the  gland  is  black  and  gangrenous  it  should 
be  removed.  Otherwise  the  cord  should  be  untwisted,  one  lateral 
surface  of  the  testicle  secured  to  the  scrotum  by  several  sutures, 
including  the  proper  tunic  of  the  gland  and  the  deeper  layers  of  the 
skin,  and  the  wound  closed.  When  the  testicle  is  greatly  swohen  and 
discolored,  even  though  it  is  not  absolutely  certain  that  gangrene  has 
taken  place,  it  is  advisable  to  remove  it  if  the  testis  on  the  other  side 
is  healthy. 

The  cases  of  hemorrhagic  infarct  reported  by  Englisch,  and  attrib- 
uted by  him  to  thrombosis  of  the  pampiniform  plexus,  were  possibly 
instances  of  torsion. 

CONTUSIONS   AND   WOUNDS   OF   THE   TESTICLE. 
Contusion. — The  testicles  from  their  position  and  mobility  usu- 
ally escape  the  effects  of  sudden  direct  pressure  applied  to  the  region 


640  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

of  the  perineum  and  scrotum.  They  may,  however,  be  pmched 
against  the  pubis  or  perineum  or  be  bruised  by  a  blow  or  a  squeeze. 
The  lightest  form  of  contusion — such  as  that  sometimes  experienced 
in  crossing  the  legs  or  riding  the  bicycle — is  attended  by  momentary 
sickening  pain,  with  a  slight  sense  of  soreness,  which  lasts  not  more 
than  a  day  or  two,  and  probably  is  not  attended  by  distinct  lesion, 
except  in  those  who  previously  have  been  subject  to  latent  disease, 
such  as  tuberculosis  or  tumor. 

Monod  and  Terrillon,  on  the  basis  of  an  experimental  investiga- 
tion, classify  testicular  contusions  as  of  three  degrees:  the  first  is 
characterized  by  minute  disseminated  capillary  hemorrhages  into  the 
connective  tissue  lying  between  the  seminal  tubules  and  the  convolu- 
tions of  the  epididymis.  There  is  often  epithelial  exfoliation  from  the 
inner  surface  of  the  epididymis.  Larger  blood  effusions  characterize 
the  second  degree,  and  there  is  laceration  of  the  tubules  ;  the  extrava- 
sations may  vary  from  the  size  of  a  pea  to  that  of  a  cherry.  The  third 
degree  of  contusion  is  characterized  by  rupture  of  the  tunica  albu- 
ginea.  The  gland  is  practically  crushed,  and  there  is  bleeding  into  the 
vaginal  tunic,  with  the  formation  of  acute  haematocele. 

Symptoms. — These  vary  in  accordance  with  the  extent  of  injury. 
Slight  contusions  are  characterized  by  a  feeling  of  faintness,  intense 
sickening  pain,  retraction  of  the  testis,  and  rather  rapid  swehing. 
When  the  contusion  is  severe  there  may  be  profound  shock  or 
almost  instant  death. 

The  first  exhausting,  almost  unbearable  anguish  is  of  compara- 
tively brief  duration.  There  follows  a  severe,  unremitting  ache, 
aggravated  by  standing,  coughing,  or  straining.  This  persists  until 
reactionary  phenomena  have  reached  their  height,  and  is  so  harassing 
that  anodynes  are  required  for  its  relief  .  The  swelling,  which  be- 
comes perceptible  within  a  very  few  minutes  and  develops  rapidly,  is 
due  in  part  to  effusion  of  blood  and  serum  into  the  vaginal  tunic,  in 
part  to  oedema  of  the  loose  cellular  tissue  of  the  scrotum.  Profound 
discoloration  is  common,  and  is  caused  by  rupture  of  the  vessels  of  the 
scrotum ;  exceptionally  it  is  due  to  bleeding  from  the  testis  and  epi- 
didymis or  cord.  The  inflammation  usually  remains  aseptic,  reaches 
its  height  in  from  five  to  eight  days,  and  subsides  slowly.  Exception- 
ally suppuration  occurs.  In  this  case,  in  place  of  subsiding,  the 
symptoms  increase  in  severity,  the  patient  suffers  from  chill  and 
fever,  redness  and  oedema  become  especially  well  marked,  and  finally 
fluctuation  is  detected. 

Prognosis. — In  slight  contusions,  characterized  by  transitory  pain 
and  disability,  lasting  at  most  a  few  hours,  the  prognosis  is  favorable. 


CONTUSIONS   AND    WOUNDS   OF    THE    TESTICLE.  641 

In  the  severer  forms  of  contusion — i.e.,  those  putting  a  patient  to  bed 
for  one  or  two  weeks — an  opinion  as  to  the  future  integrity  of  the 
testicle  should  not  be  expressed  too  confidently.  In  a  certain  num- 
ber of  such  cases  atropliy  develops,  apparently  uninfluenced  by  treat- 
ment. Atrophy  may  follow  even  slight  bruises,  and  is  most  apt  to 
occur  during  youth  ;  the  epididymis  is  usually  spared.  In  the  severest 
forms  of  contusion,  characterized  by  rupture  of  the  albuginea,  atrophy 
is  certain  to  result. 

The  atrophic  processes  may  be  progressive  and  uninterrupted,  the 
testicle  regaining  its  normal  size  on  disappearance  of  the  inflammatory 
swelling,  and  then  continuing  slowiy  to  shrink,  or  the  acute  inflamma- 
tion may  be  succeeded  by  a  condition  of  chronic  irritation,  characterized 
by  enlargement  and  tenderness  and  occasional  attacks  of  pain.  This 
chronic  pain  and  sweHing  gradually  subside,  intercurrent  subacute 
attacks  becoming  less  pronounced,  and  the  testicle  ultimately  wastes. 
This  wasting  may  affect  only  a  portion  of  the  gland,  producing  asym- 
metry ;  but  usually  the  whole  organ  is  affected,  there  remaining  when 
the  process  is  completed  a  body  of  varying  shape,  about  the  size  of  a 
Lima  bean  or  even  smaller  than  this. 

Prognosis  is  then  always  guarded,  and  becomes  less  favorable  in 
proportion  to  the  severity  and  the  persistence  of  inflammation. 

Treatment. — Even  the  mildest  forms  of  contusion  of  the  testicle 
should  not  be  neglected,  since  exceptionally  they  are  followed  by 
chronic  inflammation  and  atrophy.  In  severe  injuries,  shock  and 
syncope  are  treated  in  accordance  with  general  principles,  and  the 
agonizing  pain  is  controlled  by  the  injection  of  morphine.  The  patient 
should  be  placed  upon  his  back,  with  the  pelvis  elevated  and  the 
scrotum  supported  either  by  a  pillow  placed  close  to  the  perineum 
or  by  a  triangular  handkerchief  bandage,  the  base  of  which  is  passed 
beneath  the  scrotum,  while  its  ends  are  secured  to  a  band  about  the 
waist.  To  the  injured  testicle  cloths  kept  constantly  wet  in  lead 
water  and  alcohol  are  applied,  omitting  oiled  silk,  since  this  prevents 
the  coohng  effect  of  evaporation.  A  small  ice-bag  is  even  more  effi- 
cient, and  can  be  used  for  three  or  four  days,  a  piece  of  lint  being  kept 
between  its  surface  and  the  skin  of  the  scrotum.  If  cold  makes  the 
pain  more  severe,  hot  compresses  wrung  out  of  dilute  lead  water  and 
renewed  every  fifteen  minutes  may  be  employed,  or  lint  soaked  in 
this  same  lotion  may  be  applied,  and  over  it  may  be  placed  a  hot- 
water  bag. 

The  bowels  should  be  opened  freely,  and  when  the  swelling  is  so 
rapid  and  extensive  as  to  threaten  the  vitality  of  the  parts  there  should 
be  no  hesitation  in  cutting  down  upon  and  securing  the  bleeding  points. 


642 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


Discoloration  incident  to  scrotal  blood  effusion  should  not  be  mis- 
taken for  gangrene.  The  patient  should  be  kept  confined  to  bed 
until  the  active  inflammatory  symptoms  have  subsided,  and  may  then 
be  allowed  to  get  up,  wearing  the  pressure  suspensory  bandage  de- 
scribed in  the  section  on  the  treatment  of  epididymitis.  This  bandage 
should  be  worn  for  months,  and  the  patient  should  be  cautioned 
against  occupations  or  exercises  liable  to  cause  a  recurrence  of  inflam- 
mation. SmaU  doses  of  potassium  iodide  and  appKcation  of  mild 
counter-irritants  to  the  skin  of  the  Scrotum  are  serviceable  in  relieving 
the  chronic  congestion  which  is  liable  to  follow  upon  injury  of  the 
testis,  and  which  is  certain  to  result  in  deposition  of  fibrous  tissue 
and  subsequent  wasting  of  secreting  structure. 

Epididymo-Orchitis  from  Strain. — This  inflammation  is  prop- 
erly considered  under  the  head  of  contusion,  since  in  a  certain  pro- 
portion of  cases  the  symptoms  are  due  to  pinching  or  bruising  of  the 
testicle. 

There  develops,  without  a  preceding  urethritis  and  without  obvious 
cause,  a  swelling  which  closely  resembles  in  symptomatology  and 
course  either  epididymitis  secondary  to  gonorrhoea  or  traumatic 
epididymo-orchitis, 

Terrillon  records  the  case  of  a  man  who,  in  making  a  violent  hft- 
ing  effort,  experienced  a  sudden  pain  in  the  left  testicle  so  acute  that 
he  fainted.  There  was  no  contusion,  no  blood  effusion.  The  testis 
was  fixed  in  the  left  groin,  and  exhibited  the  tenderness,  swelling,  and 
pain  of  acute  orchitis.  Symptoms  simulating  locahzed  peritonitis 
supervened,  and  lasted  for  eight  days.  The  patient  was  confined  to 
bed  for  three  weeks.  At  the  end  of  that  time  the  testicle  had  atro- 
phied until  it  was  one-fifth  its  natural  size ;  it  was  so  tender  that 
palpation  could  not  be  endured.  The  thigh  was  flexed,  adducted, 
and  rotated  inward.  As  two  months'  further  rest  did  not  relieve  the 
symptoms,  castration  was  performed. 

From  careful  observation  of  more  than  a  dozen  of  these  cases  we 
believe  that  etiologically  they  can  be  classified  as  follows:  1.  Epi- 
didymo-orchitis due  to  a  violent  contraction  of  the  cremaster  muscle, 
which  'by  suddenly  jerking  the  testicle  against  the  pillars  of  the  ex- 
ternal ring  causes  a  bruising  of  the  former,  often  accompanied  by 
rupture  of  the  veins ;  this  is  called  "  whip-snap"  action.  When  the 
external  ring  is  patulous  the  testicle  may  be  drawn  within  its  grip 
and  may  be  further  bruised  in  this  way.  2.  Epididymo-orchitis 
from  rupture  of  the  veins.  As  a  result  of  violent  muscular  effort  and 
increased  intra-abdominal  pressure  the  often- dilated,  valveless  veins 
of  the  cord  become  enormously  congested.    This  congestion  is  further 


CONTUSIONS   AND   WOUNDS   OF   THE    TESTICLE.  643 

increased  by  compression  on  the  part  of  fibres  which  Roux  states 
pass  from  the  rectus  muscle  to  the  inner  lip  of  the  iliac  crest.  These 
fibres  participating  in  the  general  muscular  contraction  pinch  the 
cord  against  the  fibrous  circumference  of  the  external  abdominal 
ring.  Rupture  of  vessels  and  bleeding  into  the  cord,  the  epididy- 
mis, or  possibly  the  substance  of  the  testicle  result.  3.  Epididymo- 
orchitis  from  masked  lesion.  In  a  certain  number  of  cases  we  have 
been  able  to  trace  the  inflammation  to  infection  passing  from  the 
posterior  urethra  along  the  vas ;  strain  and  possible  slight  contusion 
were  undoubtedly  favoring  factors.  The  symptomatology  and  course 
of  the  inflammation  were  not  different  from  those  commonly  ob- 
served in  cases  of  chronic  posterior  urethritis.  Twice  we  have 
observed  acute  tubercular  epididymitis  develop  suddenly  after  mus- 
cular effort. 

In  accordance  with  the  cause  of  the  inflammation,  variations  in 
its  clinical  course  are  observed.  There  may  be  an  acute  epididymo- 
orchitis,  such  as  that  which  follows  ordinary  traumatism,  temporarily 
prostrating  the  patient  and  keeping  him  to  his  bed  for  days  or  weeks. 
The  inflammation  may  be  limited  almost  entirely  to  the  epididymis 
and  may  run  its  course  in  a  few  days.  Or  there  may  be  an  almost 
painless  enlargement,  neither  confining  the  patient  to  bed  nor  inter- 
fering with  his  occupation,  provided  a  suspensory  bandage  is  worn. 

The  left  testicle  is  more  frequently  involved  than  the  right ;  this  is 
what  would  naturally  be  expected  if  the  theory  of  venous  rupture 
from  pressure  is  correct. 

Prognosis. — The  prognosis  of  epididymo-orchitis  from  strain  is 
much  better  than  when  external  violence  is  the  cause.  When  the 
lesion  is  simply  hemorrhagic,  the  blood  being  found  in  the  lower  part 
of  the  cord  and  about  the  epididymis,  with  but  slight  congestion  of 
the  testicle,  atrophy  of  this  organ  is  not  to  be  feared.  When  the  in- 
flammatory attack  is  limited  chiefly  to  the  testicle  and  is  severe,  there 
is  wasting. 

Treatment — The  treatment  is  that  appropriate  to  contusion  of  the 
testicle.  Even  in  the  comparatively  painless  cases  a  properly  fitted 
pressure  suspensory  bandage  should  be  worn  for  a  long  period. 

Wounds  of  the  Testicle.— Incised  wounds  of  the  testicle  if 
kept  clean  heal  promptly.  Such  injuries  are  extremely  rare,  except 
in  the  course  of  surgical  operations,  particularly  those  undertaken  for 
the  purpose  of  establishing  diagnosis.  If  the  proper  tunic  is  opened 
and  the  testis  found  healthy,  the  albaginea  should  be  neatly  apposed 
with  catgut  sutures  and  the  external  wound  closed.  Infection  may 
be  followed  by  prolapse  of  the  secreting  substance  of  the  gland  unless 


g44  GENITO-XJRINARY   DISEASES   AJSO   SYPHILIS. 

drainage  is  promptly  established.     In  tubercular  or  syphilitic  cases 
the  so-called  benign  fungus  may  follow  incised  wounds. 

Punctured  wounds  are  usually  inflicted  by  a  misdirected  trocar. 
Provided  the  instrument  is  clean,  they  are  harmless.  If  a  dirty  instru- 
ment infects  the  testicle,  diffuse  acute  orchitis  may  develop,  with  total 
destruction  of  the  secreting  substance. 

Contused  and  lacerated  wounds,  usually  inflicted  by  bullets,  should 
be  treated  by  thorough  cleansing  and  abundant  drainage.  When  it  is 
evident  that  the  testicle  is  extensively  bruised,  castration  is  probably 
the  best  treatment.  When  both  testicles  are  involved  in  gunshot 
wounds  every  effort  should  be  made  to  preserve  even  small  portions 
of  the  secreting  substance  of  the  glands.  This  is  usually  practicable 
if  the  wound  is  kept  clean.  If  suppuration  takes  place,  complete 
atrophy  will  probably  be  the  result. 

Otis  states  that  atrophy  and  neuralgia  are  common  sequelae  of  gun- 
shot wounds  of  the  testes  when  castration  has  not  been  pei-formed. 

On  the  first  sign  of  infection  after  an  attempt  has  been  made  to 
close  a  wound  of  the  testicle,  the  stitches  should  be  removed,  the 
wound  widely  opened,  and  drainage  secured  by  gauze  packing. 

After  cleansing  and  closure  of  a  wounded  testis  and  the  application 
of  a  proper  dressing,  the  part  should  be  elevated,  and  should  be  sub- 
jected to  moderate  pressure  by  means  of  a  crossed  of  the  perineum 
bandage.  Outside  the  antiseptic  dressing  applied  immediately  over 
the  wound  is  placed  a  sufficient  quantity  of  cotton  or  crumpled  gauze 
to  equahze  the  pressure  of  the  bandage.  The  bandage  should  be 
seven  yards  long  and  three  or  four  inches  wide.  It  is  fixed  by  a  cir- 
cular turn  about  the  pelvis,  placed  beneath  the  iliac  crest.  It  is  then 
carried  downward  along  the  right  groin,  across  the  perineum,  around 
the  back  of  the  left  thigh  at  the  position  of  the  iho-femoral  fold,  up- 
ward over  the  trochanter  and  below  the  crest  of  the  ilium,  completely 
around  the  body  until  it  is  just  above  the  left  trochanter,  down  along 
the  left  groin,  across  the  perineum,  around  the  back  of  the  right 
thigh  at  the  ilio-femoral  fold,  and  upward  and  forward  over  the  right 
trochanter.  These  turns  are  repeated  until  a  firm  dressing  is  formed 
which  entirely  covers  in  the  scrotum  and  perineum. 

INFLAMMATION  OF  THE  TESTICLE. 

Inflammation  may  attack  the  epididymis,  the  testicle,  or  both  these 
structures  (epididymo-orchitis). 

From  the  etiological  stand-point  the  inflammations  can  be  classed 
as  blennorrhagic,  traumatic,  infectious,  tubercular,  and  syphilitic. 

Blennorrhagic  inflammation  is  usually  a  pure  epididymitis.     The 


INFLAMMATION   OF   THE   TESTICLE.  645 

infectious  inflammations  are,  as  a  rule,  confined  to  the  testicle.  Trau- 
matism more  commonly  produces  a  true  orchi-epididymitis.  Inflam- 
mation which  attacks  one  structure  primarily  so  frequently  invades 
the  other,  and  this  invasion  may  be  attended  by  such  slight  symptoms, 
that  it  is  impossible  from  direct  examination  to  be  certain  that  the  in- 
flammation is  strictly  limited  either  to  the  epididymis  or  the  testicle  : 
hence  the  term  orchi-epididymitis  or  epididymo-orchitis  is  often  ap- 
plied to  this  general  class  of  inflammations. 

Urethral  Epididymitis. — Gonorrhoeal  urethritis  is  the  common- 
est cause  of  epididymitis.  So  far  as  the  clinical  evidence  is  conclusive, 
there  is  reason  to  believe  that  the  inflammation  is  almost  entirely  con- 
fined to  the  epididymis  ;  it  is  probable,  however,  that  during  the  acute 
stages  the  testicle  is  more  or  less  involved.  It  is  certain  that  the  vaginal 
tunic  is  commonly  inflamed,  as  is  shown  by  the  development  of  acute 
hydrocele,  which  may  make  up  the  main  bulk  of  the  swelling. 

Epididymitis  is  a  common  seqael  of  instrumental  urethritis, — for 
instance,  that  following  the  use  of  the  lithotrite  or  frequent  catheteri- 
zation.    It  sometimes  complicates  gouty  urethritis. 

Epididymitis  is  an  expression  of  infection  carried  by  the  vas,  and 
may  complicate  any  form  of  urethritis. 

Symptoms. — The  first  prodrome  which  suggests  the  develop- 
ment of  epididymitis  is  an  aching,  sometimes  a  neuralgic,  pain 
felt  along  the  fine  of  the  groin,  often  running  down  to  the  testicle,  and 
made  much  worse  by  standing  or  walking.  If  the  cord  be  taken  be- 
tween the  thumb  and  finger  and  rolled  so  that  its  constituents  are 
separated,  the  vas  deferens  may  be  found  somewhat  enlarged  and 
tender  on  pressure.  Sometimes  there  is  neither  tenderness  nor  en- 
largement of  the  cord  to  be  detected.  If  the  inflammation  progresses, 
the  epididymis  becomes  involved  in  one  or  two  days  at  most. 

Frequently  the  disease  develops  without  any  previous  manifes- 
tations of  involvement  of  the  cord.  Suddenly  there  will  then  be  felt 
in  the  testicle  a  fixed,  dragging  pain.  The  epididymis  increases  rapidly 
in  size,  the  scrotal  covering  of  the  affected  testicle  becomes  oedematous 
and  purplish  in  color,  and  pain  is  at  times  almost  unbearable  and  of  a 
peculiar  sickening  quality  which  renders  it  diagnostic.  The  anterior 
discharge  is  generally  lessened ;  sometimes  it  entirely  ceases  for  the 
time. 

On  palpation  the  epididymis  is  found  to  be  sensitive  and  so  much 
enlarged  that  it  envelops  the  testicle  above,  behind,  and  below  in  a 
swelling  more  voluminous  than  the  gland  itself.  (Fig.  197.)  In  the 
great  majority  of  cases  the  inflammation  extends  to  the  tunica  vagir 
nalis  and  occasions  an  effusion  of  fluid,  giving  rise  to  an  acute  hydro-! 


646 


GENITO-URINAEY   DISEASES   AND    SYPHILIS. 


Fig.  197. 


cele ;  the  latter  entirely  masks  the  testicles,  so  that  on  palpation  a 
fluctuating  tumor  is  felt  in  front,  which  is  often  incorrectly  diagnosed 
as  a  swollen  testicle,  whilst  behind  is  the  enlarged,  exquisitely  tender 
epididymis. 

The  patient,  unless  the  testicle  is  supported,  walks  with  his  body 
bent  forward  and  his  legs  straddling, — a  gait  almost  pathognomonic 

of  the  ailment.  When  he 
stands,  free  return  of  blood 
is  prevented  by  the  dragging 
of  the  tumor  upon  the  sper- 
matic vessels ;  this  increases 
the  tension  and  by  additional 
pressure  upon  the  nerves 
greatly  aggravates  the  pain, 
which  sometimes  spreads  re- 
flexly  to  the  bladder,  peri- 
neum, rectum,  back,  abdo- 
men, thighs,  and  even  to  the 
thoracic  region,  and  is  almost 
unbearable. 

There  are  usually  rigors, 
fever,  and  great  mental  anxi- 
ety and  depression. 

Sometimes  acute  epididy- 
mitis in  its  onset  is  character- 
ized by  symptoms  so  violent  and  apparently  so  disconnected  from  the 
testicle  as  readily  to  occasion  a  mistaken  diagnosis.  In  these  cases  there 
will  develop,  often  in  connection  with  a  posterior  urethritis  fanned  to 
new  intensity,  violent  abdominal  pains,  accompanied  by  tympany  and 
extreme  sensitiveness  in  the  lower  part  of  the  belly ;  fever  runs  high, 
and  nausea,  green  vomiting,  and  collapse  may  follow.  These  symp- 
toms subside  almost  as  quickly  as  they  develop,  and  are  followed  by 
the  ordinary  symptoms  of  epididymitis.  The  disease  usually  reaches 
its  height  in  about  five  days. 

The  clinical  course  of  epididymitis  varies  greatly  in  individual 
cases.  Some  patients  experience  only  moderate  dragging  pain,  which 
does  not  incapacitate  them,  and  exhibit  a  somewhat  sharply  circum- 
scribed tumor  in  the  tail  of  the  epididymis,  with  possibly  slight  hydro- 
cele, and  a  little  reddening  and  induration  of  the  scrotal  skin  overlying 
the  seat  of  hardening.  In  the  majority  of  cases  the  pain,  though 
severe,  is  relieved  by  a  properly  fitting  suspensory  bandage,  and  the 
patient  is  not  forced  to  take  to  his  bed.     The  swelling  is,  however, 


Showing  the  size  and  relative  position  of  the  testicle 
and  epididymis  in  acute  epididymitis.  H,  testis ;  N.h., 
epididymis ;  S,  cord.  A,  the  swelling  is  most  marked 
about  the  head  of  the  epididymis ;  B,  the  swelling  is 
most  marked  about  the  taU.    (Kaufmann.) 


INFLAMMATION    OF   THE    TESTICLE.  g47 

usually  very  marked,  being  made  up  in  the  main  of  inflammatory  infil- 
tration in  the  loose  cellular  tissue  surrounding  the  lower  portion  of 
the  cord  and  covering  the  epididymis,  but  not  included  in  the  reflec- 
tion of  the  tunica  vaginalis.  The  redness  and  oedema  of  the  posterior 
aspect  of  the  scrotum  are  marked,  and  there  is  commonly  a  very 
appreciable  degree  of  hydrocele  present,  which  instead  of  being  gen- 
eral may  be  encysted  from  inflammatory  adhesions.  Exceptionally 
the  onset  of  the  disease  is  sudden,  the  pain  violent,  the  constitutional 
symptoms  pronounced,  the  patient  unable  to  stir  from  his  bed.  In 
these  cases  the  local  symptoms  are  usually  exceedingly  well  marked, 
tenderness,  swelhng,  cedema,  and  either  encysted  or  general  hydrocele 
are  present,  and  often  accompanying  the  inflammation  of  the  epi- 
didymis there  is  a  funiculitis  characterized  by  a  tender,  thickened  con- 
dition of  the  vas,  which  can  be  felt  on  palpation,  or  by  inflammatory 
infiltration  of  all  the  structures  of  the  cord,  forming  a  doughy,  sausage- 
shaped  tumor  thicker  than  the  thumb  and  extending  up  into  the 
inguinal  canal.  On  rectal  examination  the  thickened  tender  vas  can 
often  be  felt  very  distinctly.  When  the  funicular  portion  of  the  tunica 
vaginalis  has  not  been  obliterated  there  may  be  formed  a  true  hydro- 
cele of  the  cord.  Finally  there  are  cases  which,  though  not  exhibit- 
ing especially  severe  local  symptoms,  are  characterized  by  reflexes 
which  so  strongly  suggest  general  peritonitis  that  they  usually  occa- 
sion grave  anxiety  until  the  local  symptoms  of  epididymitis  become 
well  established.  Exceptionally,  when  the  testicle  and  its  epididymis 
are  not  normally  placed,  an  acute  epididymitis  may  lead  to  an  error 
in  diagnosis.  Thus,  when  the  testicle  is  retained  within  the  inguinal 
canal  the  early  symptoms  may  readily  simulate  those  of  a  strangu- 
lated hernia.  An  examination  of  the  scrotum,  by  showing  the  absence 
of  the  testicle  from  its  normal  position,  would  at  once  suggest  the 
diagnosis. 

The  pathological  changes  incident  to  epididymitis  consist  of  a 
catarrhal  inflammation  of  the  vas  and  epididymis,  associated  in  severe 
cases  with  oedema  and  round-cell  infiltration  of  its  walls  and  the 
surrounding  loose  connective  tissue.  In  the  tail  of  the  epididymis  are 
often  found  what  appear  to  be  foci  of  pus.  These  are  in  reality  con- 
tained in  the  seminal  canal,  and  are  made  up  of  muco-pus  and  the 
secretion  of  the  testicle. 

Prognosis. — The  prognosis  of  epididymitis  is  good,  although  cases 
are  reported  in  which  life  has  been  lost  from  extension  of  the  in- 
flammation to  the  peritoneum.  These  are  extremely  rare.  The  dis- 
ease may  undergo  complete  resolution ;  exceptionally  suppuration 
occurs.     Commonly  the  inflammatory  infiltrate,  instead  of  being  com- 


648  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

pletely  absorbed,  organizes  in  part,  and  forms  a  hard  nodule  in  the 
tail  of  the  epididymis  which  obliterates  the  efferent  duct  of  the  testicle. 
Exceptionally  there  is  a  permanent  thickening  of  the  entire  epididymis. 
The  hydrocele  not  infrequently  becomes  chronic.  Suppuration  is  de- 
noted by  increased  severity  of  the  local  inflammatory  symptoms,  by 
rigors  and  sweats,  and  Anally  by  fluctuation.  On  opening  the  abscess,. 
prolapse  of  the  entire  epididymis  sometimes  occurs  ;  when  the  suppu- 
rative inflammation  has  involved  the  testicle  proper,  this  may  be 
entirely  destroyed  in  a  short  time  by  rapid  extension  of  the  trouble ;. 
or  the  suppurative  process  may  become  chronic  and  slowly  extend, 
finally  resulting  in  destruction  of  the  gland.  Except  in  suppurative 
cases  the  testicle  is  rarely  involved  in  epididymitis,  and  hence  is  not 
materially  altered  even  though  its  efferent  duct  is  entirely  blocked. 
Very  rarely  after  the  cure  of  a  specially  severe  epididymitis  the 
testicle  slowly  atrophies.  In  this  event  it  is  probable  that  the  in- 
flammation extends  to  its^  structure,  and  as  the  infiltrate  becomes 
organized  and  exercises  pressure  the  glandular  substance  atrophies 
and  is  absorbed.  Even  though  the  inflammation  undergoes  apparent 
resolution  it  may  cause  the  development  of  latent  tuberculosis. 

The  prognosis  in  regard  to  sterility  is,  of  course,  good  when  but 
one  testicle  is  affected,  though  even  then  it  has  been  noted  that 
spermatozoa  disappear  entirely  from  the  semen  during  the  height  of 
an  attack.  When  the  epididymitis  is  bilateral  the  prognosis  must  be 
more  guarded,  though  most  of  these  cases  recover  with  functional 
testicles.  In  a  certain  proportion,  however,  especially  in  those  not 
carefully  treated,  the  epididymis  of  both  sides  becomes  obliterated 
and  the  patients  remain  sterile.  When  the  sterility  is  of  long  standing 
it  can  be  helped  only  by  operation.  (See  Sterility.)  Impotence  is 
never  a  direct  consequence  of  epididymitis. 

Pure  gonorrhoeal  epididymitis  is  much  less  likely  to  suppurate  than 
that  which  results  from  instrumental  infection,  and  this  is  in  accord- 
ance with  the  rule  governing  gonorrha3al  inflammations, — i.e.,  that 
they  are  formative  rather  than  suppurative.  Suppuration  is  compara- 
tively common  in  instrumental  epididymitis. 

The  hard  nodule  left  in  the  globus  minor  after  gonorrhoeal  epididy- 
mitis rarely  disappears  entirely.  In  attacks  of  moderate  severity  it 
may  be  impossible  after  a  time  to  decide  which  testis  was  inflamed,, 
but  years  after  a  severe  attack  an  examination  will  usually  detect 
either  a  fibroid  ma^s  or  distinct  nodular  induration.  These  indura- 
tions are  more  extensive  and  more  persistent  in  the  epididymitis  sec- 
ondary to  non-specific  posterior  urethritis.  Except  during  or  shortly 
after  an  acute  inflammatory  period,  treatment  of  these  fibrous  nodules. 


INFLAMMATION    OF    THE    TESTICLE. 


649 


is  futile.  The  nodulation  probably  renders  the  individual  sterile  so 
far  as  that  single  gland  is  concerned,  but  it  does  not  attract  his  atten- 
tion or  arouse  his  anxiety,  and  is  therefore  not  the  cause  of  hypo- 
chondriasis or  neurasthenia,  as  otherwise  it  would  be  in  the  greater 
number  of  cases.  With  the  exception  of  the  testes,  all  glands  atrophy 
when  their  ducts  are  completely  obstructed.  Curling,  Hunter,  Gosse- 
lin,  and  others  have  long  since  shown  that  the  vas  may  be  obliterated 
without  affecting  the  development  or  health  of  the  testicle.  White  and 
Kirby  have  recently  demonstrated  the  same  fact  experimentally. 

Treatment. — Prophylaxis  consists  in  the  continued  administration 
of  antiseptics  by  the  mouth,  the  proper  use  of  carefully  chosen  anti- 
septic injections  or  irrigations,  and  the  avoidance  of  intercourse, 
muscular  strain,  or  excesses  of  any  kind.  The  wearing  of  a  sus- 
pensory bandage  is  advisable.  On  the  first  prodromal  symptoms — 
i.e.,  those  of  seminal  vesiculitis,  or  dragging  pain  in  the  inguinal 
region,  or  tenderness  and  swelling  along  the  cord,  best  detected  by 
rectal  examination — the  patient  should  be  put  to  bed,  the  bowels 
should  be  freely  opened,  preferably  by  a  saMne,  the  testicles  should  be 
wrapped  in  lead  water  and  laudanum,  and  elevated  by  a  properly 
applied  handkerchief  bandage,  and  hot  compresses  and  a  hot-water 
bag  should  be  apphed  to  the  inguinal  region.  These  will  usually  limit 
the  inflammation  to  a  funiculitis,  especially  when  the  treatment  appro- 
priate to  a  posterior  urethritis  has  been  prescribed.  In  the  mild  and 
moderately  severe  cases  which  do  not  apply  for  treatment  until  the 
inflammation  of  the  epididymis  is  pronounced,  a  properly  fitted  sus- 
pensory bandage  will  usually  relieve  pain  at  once  and  bring  about 
rapid  resolution  without  requiring  the  patient  to  take  to  his  bed. 
The  bandage  employed  is  a  modification  of  the  Langlebert-Horand^ 
and  brings  to  the  rehef  of  inflamma- 
tion the  most  potent  remedies  at  the 
command  of  the  surgeon, — namely, 
heat,  moisture,  rest,  and  pressure, 
(Fig.  198.)  The  body  of  the  suspen- 
sory is  made  up  of  mackintosh,  which 
is,  in  turn,  lined  with  stout  cloth.  The 
bag  of  the  bandage  is  shafiow,  and 
at  the  sides  are  gores  which  are  pro- 
vided with  eyelets  and  laces.  When  a 
bandage  of  proper  size  is  applied  and 
strapped  tightly  it  not  only  presses  the 

testicles  upward  against  the  soft  parts  lying  anterior  to  and  just  below 
the  pubes,  but  by  the  lacings  also  exerts  lateral  pressure,  so  that  these 


Fig.  198. 


Epididymitis  suspensory  bandage. 


650  G-ElSriTO-UEIXAKY   DISEASES   A^D   SYPHILIS. 

glands  are  evenly  and  everywhere  supported.  The  method  of  apply- 
ing this  bandage  is  as  follows.  The  patient  is  placed  in  a  recumbent 
position,  and  the  testicles  and  scrotum  are  held  up  for  four  or  five 
minutes,  thus  reducing  congestion  as  much  as  possible  by  position. 
The  whole  scrotum  is  then  enveloped  in  a  thick  sheet  of  absorbent 
cotton  or  wool.  Outside  of  this  the  suspensory  bandage  is  apphed. 
It  is  strapped  on  tightly,  and  is  then  laced  at  the  sides.  When  the 
appliance  is  properly  fitted,  relief  of  pain  is  almost  inmiediate  and  is 
usually  permanent,  and  resolution  takes  place  promptly. 

In  the  severe  cases,  those  developing  suddenly  with  great  sweUing 
and  agonizing  pain,  rehef  may  sometimes  be  given  by  puncturing  with 
a  narrow-bladed  knife  the  vaginal  tunic  and  the  infiltrated  cellular 
tissue  at  the  back  of  the  scrotum.  This  operation  must  be  conducted 
under  antiseptic  precautions.  It  may  be  rendered  painless  by  the 
preliminary  injection  of  a  few  drops  of  cocaine,  and  should  be  per- 
formed with  a  straight,  narrow-bladed  knife,  the  latter  being  driven 
in  at  the  point  where  the  swelling,  redness,  oedema,  and  tenderness 
are  most  pronounced,  usually  at  the  back  of  the  scrotum  and  at 
about  the  middle  of  the  epididymis.  Following  puncture  there  is 
usually  the  escape  of  a  few  drops  of  serum,  which  generally  spurts 
out  as  if  under  considerable  pressure,  with  almost  immediate  lessening 
of  pain.  The  seat  of  puncture  should  be  covered  with  a  small  anti- 
septic dressing,  held  in  place  with  cohodion,  after  which  the  pressure 
suspensory  bandage  above  described  may  be  employed. 

The  scrotum  should  be  elevated  by  means  of  a  handkerchief 
suspensory  bandage  folded  in  the  form  of  a  triangle,  with  its 
base  placed  beneath  and  behind  the  testicles  and  its  two  ends 
carried  up  over  the  front  of  the  belly  and  secured  to  a  band  about 
the  waist.  By  carrying  the  third  corner  of  this  triangle  upward 
and  securing  it  to  the  waistband  the  testicles  are  kept  effectually 
elevated.  They  should  be  swathed  in  lint  kept  constantly  wet  with 
a  saturated  solution  of  magnesium  sulphate,  or  with  the  following 
mixture : 

R   Tinct.  aconiti, 

Tinct.  opii,  aa  f  gi  ; 

Liq.  plumbi  subacetatis, 

Aqua?,  aa  foii. 
M.  S. — For  external  use. 


INFLAMMATION   OF   THE    TESTICLE.  (551 

If  the  pain  is  unrelieved  the  patient  should  be  given  a  genera] 
anaesthetic  and  the  suppurating  area  should  be  opened  and  drained  in 
accordance  with  general  surgical  principles.  Each  morning  the  patient 
should  take  half  a  bottle  of  effervescing  magnesium  citrate.  Hypo- 
dermic injections  of  morphine  are  usually  required  in  severe  cases. 
When  these  are  distinctly  contra-indicated  and  other  means  of  reliev- 
ing pain  have  failed,  Roussy,  on  the  basis  of  experience  with  thirty- 
four  cases,  advises  epidural  injections  of  three  to  four  cubic  centimetres 
of  a  one  per  cent,  solution  of  cocaine.  The  technique  of  this  injection 
is  that  employed  in  the  treatment  of  incontinence  of  urine.  (See  page 
326.)  Conditions  that  would  justify  its  employment  are  of  the  greatest 
rarity.  The  diet  should  be  restricted,  and  the  fever  should  be  combated 
by  potassium  bromide  five  grains  and  tincture  of  aconite  one  drop, 
given  every  two  hours. 

When  the  acute  inflammatory  symptoms  have  subsided, — i.e.,  when 
the  pain  has  lessened  and  is  severe  only  upon  motion,  and  the  epi- 
didymis and  the  surrounding  cellular  tissue  form  a  large  solid  mass, — 
pressure  is  always  indicated.  This  is  best  applied  by  means  of  a  sus- 
pensory bandage,  as  already  described,  or  through  the  medium  of  a 
strip  of  rubber  dam  eight  to  ten  inches  long  and  half  as  wide.  The 
testicle  is  tightly  encircled  in  this  bandage,  the  final  turn  of  which  is 
secured  by  a  strip  of  adhesive  plaster.  From  the  very  beginning  of 
the  attack  when  a  sweating  suspensory  bandage  has  been  used  a 
twenty  to  fifty  per  cent,  guaiacol  ointment  spread  on  lint  and  applied 
within  the  suspensory  serves  as  a  useful  counterirritant. 

When  all  inflammatory  swelling  has  disappeared,  but  an  indu- 
rated nodule  persists,  the  pressure  suspensory  bandage  should  still  be 
employed  in  conjunction  with  an  ointment  made  of  belladonna  oint- 
ment and  mercuric  ointment  equal  parts,  and  internally  five  grains  of 
potassium  iodide  should  be  given  three  times  a  day. 

The  treatment  of  all  forms  of  epididymitis  due  to  extension  of  in- 
flammation from  the  posterior  urethra  is  conducted  on  the  lines  laid 
down  in  regard  to  the  gonorrhoeal  variety.  Urethritis  which  is  intensi- 
fied by  gout  should  be  subjected  to  antilithsemic  remedies,  and  appro- 
priate diet  and  hygiene  should  be  ordered.  The  harassing  recurring 
epididymitis  from  which  prostatics  who  are  compelled  to  pass  the 
catheter  suffer  should  be  prevented  by  vasectomy,  and  the  operation 
should  be  performed  for  the  relief  of  all  forms  of  recurring  epididy- 
mitis of  urethral  origin  when  the  patient  is  past  the  procreative  age. 
For  the  operative  cure  of  sterility  following  double  obliterating  epididy- 
mitis, see  page  802. 


652  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

Epididymo-Orchitis  complicating  Acute  Infectious  Dis- 
eases.— Under  this  general  heading  are  included  orchitis  of  mumps, 
variola,  typhoid,  malaria,  scarlatina,  influenza,  and  possibly  gout. 
Inflammation  in  most  of  these  cases  is  of  pure  haematogenous  origin, 
dependent  upon  toxic  substances  circulating  in  the  blood.  It  appar- 
ently attacks  primarily  and  most  severely  the  testicle.  When  the 
disease  develops  in  its  acute  form  the  symptoms  are  even  more 
marked  than  those  of  acute  epididymitis.  In  the  latter  affection  the 
bulk  of  the  tumor  is  formed  by  the  epididymis,  which  partly  envelops 
the  testis  as  would  a  hand  a  small  kidney.  In  orchitis  the  main 
swelling  is  formed  by  the  testicle,  this  gland,  even  though  enormously 
swollen,  maintaining  its  normal  form  ;  the  epididymis  if  uninvolved  is 
stretched  as  a  narrow  band  along  its  posterior  border.  The  general 
testicular  sensibility  is  greatly  increased.  In  epididymitis  the  tender- 
ness is  limited  mainly  to  the  epididymis  itself.  Acute  hydrocele  may 
occur  coincidently  with  the  swelhng  of  the  testicle,  but  is  much  less 
common  than  when  the  epididymis  is  involved.  Exceptionally  sup- 
puration ensues  ;  this  is  nearly  always  preceded  by  great  oedema  and 
discoloration  of  the  scrotum  and  by  pronounced  constitutional  symp- 
toms. 

The  differential  diagnosis  between  orchitis  and  epididymitis  is 
based  mainly  upon  the  form  of  the  swelling.  When  the  tissues  of  the 
scrotum  become  markedly  oedematous,  and  particularly  when  hydro- 
cele develops,  a  differential  diagnosis  may  be  impossible  ;  nor  is  this 
of  cardinal  importance. 

Orchitis  complicating  Mumps. — Inflammation  of  the  testicle  is 
sometimes  the  sole  expression  of  mumps ;  it  runs  an  acute  course, 
terminating  in  a  few  days  or  a  few  weeks. 

It  may  be  ushered  in  by  a  rise  of  temperature,  and  generally  de- 
velops from  the  fourth  to  the  sixth  day  of  the  disease.  As  a  rule, 
only  one  testis  is  involved.  Catrin,  basing  his  conclusion  on  a  study 
of  one  hundred  and  fifty-nine  cases  of  mumps,  states  that  orchitis 
occurs  in  one  out  of  three  cases,  usually  develops  after  the  parotiditis, 
and  begins  in  the  epididymis,  the  body  of  the  gland  being  subse- 
quently attacked.  Atrophy  of  the  organ  is  rarer  than  is  usually  sup- 
posed. In  a  certain  number  of  cases  after  a  period  of  atrophy  and 
loss  of  consistency  the  testicle  regains  its  original  volume  and  firmness. 
If  both  testes  become  involved  the  inflammation  is  usually  consecutive. 

In  contradiction  to  the  statement  above  quoted,  we  believe  that  the 
inflammation  of  this  form  of  orchitis  begins  in  the  gland  and  not  in  the 
epididymis,  and  that  incurable  atrophy  is  a  much  commoner  sequel 
than  is  generally  conceded.     Hornus  observed  a  fatal  case  of  orchitis 


INFLAMMATION    OF    THE   TESTICLE.  653 

consecutive  to  mumps.  Death  was  caused  by  peritonitis,  the  testicles 
having  been  absolutely  destroyed  and  converted  into  a  purulent 
collection. 

As  to  the  etiology  of  the  testicular  affection,  the  theory  of  metas- 
tasis is  absolutely  inadequate,  since  it  really  gives  no  explanation,  but 
merely  a  word  to  describe  what  is  not  understood.  Kocher  states 
that  orchitis  after  mumps  is  urethral,  the  specific  inflammation  excited 
by  the  organism  first  involving  the  urethral  mucous  membrane  and 
then  extending  along  the  vas.  If  this  were  true,  we  should  expect 
the  inflammation  to  develop  first  in  the  epididymis,  as  in  the  case  of 
most  inflammations  of  urethral  origin.  With  the  exception  of  Catrin, 
authors  generally  teach  that  the  testis  is  primarily  involved.  The 
symptoms  of  mumps  orchitis  are  pain,  swelling,  exquisite  tenderness, 
and  fever  of  moderate  degree.  Exceptionally  the  attack  is  ushered  in 
with  typical  symptoms  of  acute  peritonitis, — i.e.,  vomiting,  constipation, 
tympany,  and  peritoneal  tenderness  ;  still  more  rarely  by  acute  neph- 
ritis with  uraemia. 

Diagnosis. — The  diagnosis  is  founded  upon  associated  symptoms 
of  parotiditis,  or,  in  the  rare  cases  when  these  are  latent  or  absent, 
upon  the  possibility  of  contagion  and  the  exclusion  of  other  sufficient 
causes  of  inflammation. 

Prognosis. — This,  we  think,  should  always  be  guarded.  In  light 
attacks  characterized  by  moderate  swelling  the  prognosis  is  doubtless 
favorable.  In  severe  attacks  with  pronounced  general  symptoms, 
and  especially  when  the  attack  is  prolonged,  atrophy  is  always  to  be 
dreaded. 

Treatment. — The  measures  already  described  as  appropriate  to 
orchitis  and  epididymitis  are  indicated  when  the  testis  becomes 
inflamed  as  an  expression  of  mumps. 

As  a  prophylactic  treatment  in  all  cases  of  parotiditis  it  is  well  to 
support  the  scrotum  by  a  soft  flannel  binder  or  a  suspensory  bandage, 
in  accordance  with  the  age  of  the  patient.  Moreover,  since  this  is 
an  infectious  disease,  as  illustrated  by  the  formation  of  erythematous 
nodules,  involvement  of  the  kidneys  or  meninges,  the  development  of 
various  inflammations,  dysentery,  vomiting,  and  the  general  symp- 
toms of  infection,  it  would  seem  wise  to  administer  salol  and  boric 
acid,  with  the  purpose  of  rendering  the  urine  slightly  antiseptic  and 
thus  preventing  inflammation  of  the  posterior  urethra  which  might  ex- 
tend along  the  vas.  The  comparatively  unyielding  tunica  albuginea 
subjects  the  secreting  substance  of  the  testis  to  fatal  pressure  when 
inflammation  is  pronounced  or  is  of  long  standing.  This  can  be 
relieved  at  once  by  incision  or  puncture.     The  profession  has  been 


654  GENITO-URINARY   DISEASES   AND   biTHILIS. 

deterred  from  this  form  of  intervention  by  the  fear  of  hernia  testis, — 
i.e.,  extrusion  of  the  secreting  substance  of  the  testicle.  When  this 
has  occurred  it  has  been  in  consequence  of  infection  ;  even  though  a 
certain  amount  of  testicular  substance  should  be  lost  as  a  result  of 
incision,  it  is  probable  that  the  ultimate  functional  power  of  the  organ 
would  be  better  than  it  is  when  tension  has  been  unrelieved. 

Typhoid  orchitis  is  commonest  before  the  age  of  puberty.  As  a 
rule,  it  is  mild  in  type  and  occurs  during  convalescence.  It  is  not 
definitely  settled  whether  the  testis  or  the  epididymis  is  primarily  in- 
volved. The  etiology  of  this  condition  is  sometimes  dependent  on 
venous  thrombosis,  though  it  may  be  the  result  of  infection  from  the 
urethra  or  through  the  agency  of  the  blood.  The  typhoid  bacillus  has 
been  found  in  suppurative  cases.     Atrophy  is  rare. 

Malarial  Orchitis. — This  form  of  inflammation  is  chronic  in  type, 
with  acute  paroxysms,  sometimes  recurring  regularly.  In  one  case 
we  noted  acute  pain  and  exquisite  tenderness  developing  daily  with 
the  regularity  that  characterizes  a  quotidian  type  of  malaria.  The 
condition  yielded  promptly  and  completely  to  full  doses  of  quinine. 

Le  Dentu  states  that  the  testicle  slowly  increases  in  size,  be- 
coming elephantiasic.  He  describes  a  form  of  overgrowth  associated 
with  elephantiasis  of  the  scrotum  and  evidently  dependent  upon  in- 
volvement of  the  lymphatic  system.  This  is  characterized  by  recur- 
rent erysipelatoid  attacks,  with  gradual  deposition  of  partially  organ- 
ized fibrous  tissue.  It  is  probable  that  this  is  not  malarial  orchitis, 
but  a  distinct  affection. 

The  principal  diagnostic  features  of  malarial  orchitis  are  the  recur- 
rence of  attacks  and  the  absence  of  other  sufficient  cause  for  the 
symptoms.  Full  dosage  with  quinine  will  estabhsh  the  diagnosis  and 
relieve  the  condition. 

Orchitis  following  tonsillitis  is  an  expression  of  infection  which 
may  be  hsematogenous  or  may  be  carried  from  the  urethra.  The 
course  of  the  affection  is  similar  to  that  of  orchitis  complicating  mumps. 
The  disease  lasts  two  or  three  weeks  and  usually  teririinates  in  resolu- 
tion, but  may  suppurate  or  become  chronic,  in  either  case  ultimately 
causing  atrophy. 

Gouty  orchitis  is  found  associated  with  the  usual  phenomena  of 
gout.  It  may  be  acute  or  chronic  in  type,  and  is  likely  to  be  per- 
sistent. It  may,  however,  alternate  with  other  gouty  symptoms,  dis- 
appearing with  the  arthritis  and  reappearing  as  the  latter  subsides.  It 
is  prone  to  relapse,  occurring  in  sudden  seizures,  and  may  be  trans- 
ferred from  one  testicle  to  the  other.  True  gouty  orchitis  is  quite 
different  from  the  epididymitis  of  urethral  origin  observed  in  gouty 


IJSrrLAMMATlON    OF    THE    TESTICLE.  ^55 

persons.  It  occurs  after  middle  life,  and  affects  primarily  and  chiefly 
the  testes,  rarely  extending  to  the  epididymis. 

Orchitis  following  small-pox,  scarlatina,  or  influenza  has  no 
pathognomonic  features.  It  is  simply  a  local  expression  of  a  general 
infection,  due  either  to  lodgement  of  micro-organisms  circulating  in 
the  blood  or  to  extension  by  means  of  a  phlebitis,  especially  of  the 
spermatic  veins. 

Traumatic  orchitis  has  been  already  discussed. 

By  whatever  cause  orchitis  or  orchi-epididymitis  is  excited,  the 
lesions,  symptoms,  and  terminations  are  practically  the  same,  with 
minor  differences  dependent  upon  a  difference  in  the  virulence  of  the 
infection  and  upon  varying  individual  power  of  resistance.  The  dis- 
tinction between  inflammations  of  urethral  and  those  of  haematoge- 
nous  origin  is  important  mainly  from  a  therapeutic  stand-point,  since 
a  posterior  urethritis  if  present  should  receive  attention. 

The  inflammation  may  terminate  in  complete  resolution  with 
restoration  of  physiological  function,  in  chronic  inflammation  followed 
by  atrophy  and  loss  of  function,  or  in  abscess  often  complicated  by 
fungus  of  the  testicle.  Gangrene  is  a  rare  complication  occurring  in 
debilitated  patients.  Exceptionally  the  inflammation  extends  along  the 
cord,  occasioning  pelvic  cellulitis  and  peritonitis.  We  believe,  how- 
ever, that  most  of  the  reported  cases  of  this  extension  are  in  reality 
instances  of  suppuration  of  the  seminal  vesicles.  The  initial  cause  of 
chronic  inflammation  is  usually  a  preceding  acute  orchitis,  although 
underlying  this  there  is  often  a  constitutional  dyscrasia.  Either  the 
testicle  becomes  indurated  and  completely  atrophies,  or  suppuration 
takes  place,  producing  multiple  abscess. 

Treatment. — Acute  orchitis  is  treated  by  the  remedies  and  appli- 
cations described  as  appropriate  to  gonorrhoeal  epididymitis.  The 
indications  are  met  by  rest  in  bed,  elevation  of  the  pelvis  and  the 
testicles,  the  application  of  evaporating  lotions  or  the  ice-bag,  or  hot 
fomentations,  according  to  the  severity  of  the  inflammation,  securing 
a  soluble  condition  of  the  bowels,  and  the  administration  of  febrifuges 
and  diuretics,  and  of  morphine  hypodermically  in  sufficient  doses  to 
control  the  severe  pain. 

If  the  pain  is  so  intense  that  safe  doses  of  morphine  Avill  not 
relieve  it,  the  tunica  albuginea  may  be  punctured.  The  punctures 
should  be  made  with  a  straight  cataract  knife  ;  they  may  be  multiple 
and  may  be  repeated  several  times.  The  importance  of  guarding 
against  infection  is  evident.  Abscesses  should  be  opened  and  drained 
by  gauze  packing ;  rheumatic  and  gouty  cases  should  receive  appro- 
priate constitutional  treatment,  and  invariably  on  the  subsidence  of 


,^56  GENITO-UKINAPvY   DISEASES   AND   SYPHILIS. 

acute  inflammation  the  general  treatment  of  tiie  patient  should  be  tonic 
and  supporting. 

As  soon  as  patients  are  able  to  leave  bed,  and  when  the  inflam- 
mation is  moderately  severe  this  should  not  be  under  two  or  three 
weeks,  a  carefully  fitted  pressure  suspensory  bandage  should  be  worn, 
preferably  that  described  in  the  treatment  of  gonorrhoeal  epididy- 
mitis, and  this  should  be  continued  for  months  or  until  the  testicle 
returns  to  its  normal  condition.  At  the  same  time  a  slightly  stimu- 
lating ointment  applied  to  the  scrotal  skin  will  be  serviceable.  One 
reason  that  acute  orchitis  and  orchi-epididymitis  run  into  the  chronic 
form  and  produce  slow  destruction  of  the  secreting  portion  of  the 
testes  is  that  patients  are  allowed  to  be  up  and  about  before  the  blood- 
vessels have  regained  their  tonicity,  and  hence  there  results  a  condition 
of  chronic  congestion  in  a  previously  inflamed  organ.  Prolonged 
rest  in  bed  and  an  accurately  fitting  pressure  bandage  are  the  means 
of  treatment  which  offer  most  hope  of  avoiding  this  complication. 

Abscess  of  the  Testicle. — Reference  has  been  already  made  to 
abscess  as  a  comparatively  rare  termination  of  acute  or  chronic  or- 
chitis and  epididymitis.  In  tubercular,  malignant,  or  syphilitic  degen- 
eration of  the  testes  pus-formation  is  common.  In  gonorrhcea  and 
mumps  it  is  rarer  than  in  other  acute  infectious  diseases.  It  is  prob- 
ably most  frequent  in  the  epididymo-orchitis  which  develops  in  old 
men  in  consequence  of  catheter  urethritis. 

A  small  abscess  having  formed  in  the  testis,  it  may  become  en- 
cysted, undergoing  caseous  degeneration ;  or  may  spread  beneath  the 
tunica  albuginea,  involving  the  whole  testis  and  causing  sloughing, 
followed  by  many  openings  ;  or  may  rupture  into  the  tunica  vaginalis, 
causing  suppuration  of  this  sac  and  ultimately  pointing  externally ;  or 
the  abscess  may  reach  the  surface  without  rupturing  into  the  cavity 
of  the  tunica  vaginalis,  inflammatory  adhesions  gluing  all  the  tissues 
together  before  the  pus  breaks  through  the  tunica  albuginea. 

Sometimes  the  abscess  when  centrally  placed  may  remain  quies- 
cent for  an  indefinite  period,  occasionally  exhibiting  acute  exacer- 
bations. It  should  be  remembered  that  gangrene  of  the  testis  may 
occur  as  a  consequence  of  a  very  small  abscess. 

The  symptoms  of  suppuration  are  those  of  an  aggravated  orchitis. 
Usually  there  is  fever  and  the  oedematous  swelling  of  the  scrotum  be- 
comes more  pronounced.  Following  incision  or  spontaneous  evacua- 
tion, fungus  of  the  testicle  may  develop,  the  whole  of  the  secreting 
substance  of  the  gland  being  extruded. 

Treatment — Early  free  incision,  followed  by  irrigation  and  gauze 
packing,-  is   the   treatment  best  calculated  to   relieve   tension,    and 


INFLAMMATION   OF   THE    TESTICLE.  657 

therefore  to  lessen  the  danger  of  acute  tissue  necrosis.  Healing  is 
usually  prompt.  When  the  whole  testis  is  riddled  with  abscesses,  or 
when  sloughing  has  taken  place,  castration  is  the  operation  of  choice. 

Gangrene  or  Necrosis  of  the  Testicle  may  be  due  to  throm- 
bosis or  endarteritis  of  the  spermatic  artery,  torsion  of  the  spermatic 
cord,  or  hyperacute  inflammation  of  the  gland.    Castration  is  indicated. 

Fungus  or  Hernia  of  the  Testicle. — There  are  two  varieties : 
(1)  true  or  glandular  fungus,  made  up  of  a  mass  of  granulation-tissue, 
which  sometimes  contains  seminiferous  tubules,  growing  from  within 
the  tunica  albuginea ;  (2)  false  or  parietal  fungus,  consisting  of 
exuberant  granulations  springing  from  the  tissues  of  the  scrotum  or 
from  the  surface  of  the  tunica  albuginea. 

Fungus  of  the  testicle  may  be  caused  by  suppuration,  gangrene, 
syphilis,  or  tuberculosis.  Rectus  states  that  hernia  of  the  testis  implies 
protrusion  of  the  gland  still  covered  with  its  fibrous  envelope  through 
an  opening  in  the  scrotum.  Scrotal  tuberculosis,  inflammation,  gan- 
grene, and  traumatism  may  destroy  the  scrotum  and  allow  the  testicle 
to  protrude. 

The  older  writers  described  a  hernia  testis  apparently  due  to  simple 
infection  following,  for  instance,  such  a  procedure  as  puncture  of  the 
tunica  albuginea  for  relief  of  pain  in  a  gonorrhoeal  epididymitis.  We 
have  once  encountered  such  a  condition  which  was  neither  tuber- 
cular nor  syphilitic,  but  was  an  instance  of  sloughing  testis,  in  which 
the  devitalized  tissues  gradually  escaped  though  an  infected  and  bruised 
trochar  opening. 

Fungus  which  accompanies  suppurative  or  sloughing  processes 
may  be  made  up  entirely  of  granulation-tissue.  This  is  always  the 
case  in  the  parietal  form  of  the  affection.  In  the  glandular  or  deep 
form  the  tubular  structure  of  the  testis  is  often  extruded,  though 
absence  of  the  tubules  in  the  slough  and  discharge  does  not  prove 
that  the  granulations  do  not  grow  from  the  gland. 

The  tubercular  fungus  may  be  superficial  or  deep,  and  is  made 
up  of  exuberant  granulations  from  the  walls  of  an  abscess.  These 
protrude  through  openings  in  the  scrotum  which  exhibit  indurated, 
chronically  inflamed,  gradually  contracting  borders ;  they  appear  as 
yellowish-red,  painless,  cauliflower-like  growths,  overlapping  the 
scrotal  defect,  rarely  larger  than  the  end  of  the  thumb,  though  in  the 
glandular  variety  the  greater  part  of  the  testicular  substance  may  be 
extruded. 

The  syphilitic  fungus  grows  from  the  walls  of  a  discharging  gumma ; 
it  may  be  intra-  or  extra-glandular ;  it  rarely  attains '  the  size  of  the 
larger  tubercular  fungus. 

42 


658  GENITO-UKINAKY  DISEASES   AND   SYPHILIS. 

The  malignant  fungus  (fungus  heematodes)  is  in  reality  a  new 
growth  which  has  broken  through  the  tissues  of  the  scrotum. 

Diagnosis. — The  appearance  of  an  irregular,  red,  granulating  mass 
protruding  through  an  opening  in  the  scrotum  is  so  characteristic  of 
fungus  that  the  diagnosis  is  formulated  on  sight.  The  nature  of  the 
growth  may,  however,  require  careful  study.  The  history  of  the 
case,  particularly  that  of  the  development  of  the  preceding  orchitis,  is 
usually  characteristic.  The  finding  of  the  seminiferous  tubules  and 
the  detection  of  a  distinct  pedicle  to  the  growth  show  that  it  originates 
from  the  glandular  substance. 

Treatment. — This  depends  upon  the  cause  and  the  variety  of  the 
fungus.  Syphilitic  cases  are  cured  by  appropriate  constitutional  treat- 
ment, supplemented  by  cutting  away  the  exuberant  granulations  and 
dressing  the  wound  with  sterile  gauze.  Tubercular  cases,  if  super- 
ficial, may  be  cured  by  touching  with  caustic  potash  and  dressing  with 
iodoform  gauze.  If  deep,  they  should  be  opened,  curetted  from  the 
bottom,  and  packed  ;  if  persistent  and  associated  with  extensive  de- 
generation of  the  testicle,  castration  should  be  performed.  Fungus 
hsematodes  (malignant)  should  be  treated  by  castration. 

The  fungus  which  complicates  simple  abscess  or  sloughing,  and 
which  springs  from  the  glandular  substance,  being  made  up  of  granu- 
lation-tissue and  sometimes  of  seminiferous  tubules,  should  be  opened 
and  curetted  and  the  resulting  wound  packed  with  iodoform  gauze. 

TUBERCULAR   DISEASE  OF  THE   TESTICLE. 

Tubercular  inflammation  may  develop  in  one  of  two  forms: 
either  as  a  sudden  outbreak  with  all  the  local  and  general  symptoms 
of  acute  inflammation,  leaving  on  subsidence  an  irregular  nodulation 
characteristic  of  tuberculosis,  or  as  a  slow,  apparently  non-inflam- 
matory, almost  painless  formation  of  tubercular  nodules. 

The  infection  may  reach  the  testicles  through  the  blood-channels 
or  may  extend  by  continuity  of  structure  along  the  vas.  Occasionally 
the  testicles  and  the  epididymis  are  affected  during  the  evolution  of  a 
general  miliary  tuberculosis.  The  lodgement  of  the  tubercle  bacifli 
may  be  primary  in  the  epididymis,  or  the  infection  may  be  secondary 
to  prostatic,  vesical,  or  renal  tuberculosis,  or  to  foci  of  the  disease  in 
other  parts  of  the  body. 

So  far  as  clinical  evidence  goes,  the  epididymis  appears  to  be 
a  frequent  seat  of  primary  tuberculosis ;  from  this  organ  as  the 
starting-point  the  disease  extends  along  the  genito-urinary  tract. 
Saltzmann  defends  the  theory  of  the  entrance  of  the  bacilli  by  way 
of  the  blood-vessels  on  the  ground  that  the  arteries  of  the  epididymis 


TUBERCULAK   DISEASE    OF    THE   TESTICLE.  659 

are  smaller  and  more  tortuous  than  those  of  the  testicle  or  of  the 
vas,  and  that  thus  bacilli  floating  in  the  blood  are  more  liable  to 
be  lodged.  Moreover,  the  spermatic  artery  bifurcates  just  before  it 
enters  the  epididymis. 

It  is  possible  that  infection  may  take  place  during  coitus.  Ver- 
neuil  strongly  defends  this  theory.  He  demonstrates  the  presence  of 
tubercle  bacilli  in  the  discharges  of  patients  suffering  from  uterine 
tuberculosis.  He  also  cites  cases  in  which  the  disease — i.e.,  tuber- 
cular epididymitis — appeared  in  persons  of  perfectly  healthy  consti- 
tution after  sexual  intercourse  and  where  no  gonorrhoeal  history 
existed.  Further,  the  tubercular  infection  is  most  likely  to  develop  at 
that  age  when  sexual  activity  is  greatest,  and  in  the  early  stages  of 
genital  tuberculosis  there  is  no  interference  with  sexual  desire  or 
potency.  This  behef  in  immediate  tubercular  contagion  is  sufficiently 
well  grounded  to  justify  a  careful  examination  of  uterine  and  vaginal 
discharges  in  suspected  cases,  and,  when  bacilli  are  found,  to  make  it 
desirable  to  suggest  means  of  prophylaxis. 

Tubercle  bacilli  have  been  found  in  the  healthy  testicle  and  epi- 
didymis. It  is  also  proved  that  these  organisms  may  circulate  in  the 
blood  without  obtaining  lodgement  in  the  tissues,  and  consequently 
without  working  deleteriously  upon  the  system  until  acute  inflam- 
mation, particularly  that  following  traumatism,  produces  a  local  lessen- 
ing of  resistance  which  favors  the  lodgement  and  multiplication  of 
the  micro-organisms.  This  has  been  shown  experimentally  by  intra- 
peritoneal injection  of  tubercular  sputum  followed  by  contusion  of 
the  testis,  and  it  explains  the  frequency  with  which  an  acute  gonor- 
rhoeal epididymitis  or  an  orchitis  incident  to  traumatism  is  followed 
by  a  tubercular  infiltration. 

In  the  large  majority  of  cases  tubercular  infiltration  is  first  noted 
in  the  head  of  the  epididymis,  appearing  as  inflammatory  nodules 
which  sooner  or  later  undergo  cheesy  degeneration.  The  epididymis 
becomes  irregularly  infiltrated,  and  the  vas  thickened,  hard,  and 
nodular.  The  disease  also  extends  in  the  direction  of  the  testis,  and 
not  infrequently  the  vaginal  tunic  is  involved.  When  the  testis  is 
infected,  similar  nodules  develop  and  show  a  central  degeneration, 
extending  at  the  same  time  peripherally,  and  finally  forming  a  com- 
paratively large  cavity. 

Though  from  clinical  examination  in  the  vast  majority  of  cases 
tuberculosis  seems  primarily  to  involve  the  epididymis,  entirely 
sparing  the  testis,  Reclus  has  shown  by  post-mortem  dissection  that 
both  epididymis  and  testis  are  involved  in  more  than  three-fourths 
of  the  cases.     In  twenty-two  cases  in  which  no  autopsy  was  made, 


660 


GENITO-URIJNARY  DISEASES   AND   SYPHILIS. 


tubercles  were  palpably  present  in  the  epididymes  and  testicles  in  ten 
cases,  and  only  in  the  epididymes  in  twelve  cases. 

Symptoms. — Tubercular  epididymo-orchitis  may  develop  abruptly 
or  insidiously,  or  may  be  preceded  by  certain  highly  characteristic 
prodromal  symptoms. 

The  abrupt  development  of  the  disease  is  usually  dependent  upon 
slight  trauma  or  extension  of  inflammation  from  posterior  urethritis. 
The  symptoms  are  practically  the  same  as  those  of  traumatic  orchitis 
or  of  gonorrhceal  epididymitis.  There  are  the  characteristic  sickening 
pain,  effusion  into  the  tunica  vaginalis  and  the  cellular  tissues  about 
the  epididymis,  and  general  cedema.  Instead  of  subsiding  in  the 
course  of  a  few  days  or  one  or  two  weeks,  the  local  swelling  persists, 
though  pain  may  be  almost  entirely  reheved.  In  a  few  weeks  fluctu- 
ation may  be  detected,  and  one  or  more  sinuses  form,  discharging 
cheesy  pus. 

This  inflammation  is  commonly  an  epididymo-orchitis,  and  is 
often  bilateral.  It  attacks  by  preference  young  adults,  and  is  first 
lodged  in  the  epididymis,  the  outlines  of  which  are  so  obscured  by  a 
large  bossed  swelling  that  the  loop  formed  by  the  vas  deferens  cannot 
be  felt  (Reclus) ;  the  vas  is  often  infiltrated,  and  there  is  generally 
tubercular  involvement  of  the  other  genito-urinary  organs,  particu- 
larly the  prostate  and  seminal  vesicles.  Except  during  the  period 
of  acute  outbreak  there  is  little  or  no  pain.  Fistula  may  not  form 
for  a  long  time,  the  acute  swelling  partially  subsiding  and  allowing  the 
nodular,  indurated,  and  enlarged  epididymis  and  vas  to  be  readily  pal- 
pated. Hydrocele  generally  develops  in  connection  with  this  form  of 
tuberculosis,  and  is  likely  to  be  of  the  agglutinative  type.  In  the  dis- 
charge from  the  sinuses  tubercle 
Fig.  199.  bacilli  may  be  found. 

The  insidious  form  of  the  dis- 
ease is  characterized  by  the  slow, 
painless  formation  of  nodules 
either  in  the  epididymis  or  in  the 
testicle,  or  in  both  these  organs. 
(Fig.  199.)  Often  there  are  abso- 
lutely no  symptoms,  the  patient 
detecting  the  overgrowth  acci- 
dentally. Sometimes  there  is  a 
sense  of  dragging  and  weight,  or 
there  are  reflex  disturbances,  such 
as  frequent  emissions  or  sexual  hyperaesthesia,  which  lead  to  exam- 
ination of  the  part  and  discovery  of  the  swelling. 


Tubercular  epididymitis.    (Monod  and  Terrillon.) 


TUBERCULAE   DISEASE   OF   THE   TESTICLE.  661 

The  form  of  the  disease  ushered  in  by  prodromata  is  probably 
not  primary, — i.e.,  there  is  a  pre-existing  tubercular  involvement  of 
some  other  portion  of  the  genito-urinary  tract.  The  prodromal 
symptoms  are — (1)  A  painless,  moderate  urethritis,  characterized  by 
a  scanty,  turbid,  muco-purulent  discharge,  noticeable  only  in  the 
morning.  This  discharge  comes  and  goes  apparently  without  cause, 
and  is  uninfluenced  by  treatment.  (2)  Frequent  urination.  (3)  A 
hypersensitive  condition  of  the  prostatic  urethra,  particularly  to  in- 
strumental examination  and  irritating  injections.  (4)  Terminal  liEema- 
turia.  These  symptoms  may  last  weeks  or  months  before  appreciable 
development  of  lesions  in  the  testicle  or  the  epididymis,  and  indicate 
tubercular  involvement  of  the  posterior  urethra. 

In  the  chronic  forms  of  tubercular  involvement  of  the  testicle 
and  epididymis  suppuration  and  abscess-formation  develop  much 
more  slowly  than  in  the  acute.  Even  large  infiltrations  become 
encapsulated  and  absorbed,  leaving  simply  an  irregular  fibroid  nodu- 
lation.  We  have  under  observation  cases  of  tubercular  epididymo- 
orchitis  which  have  lasted  from  four  to  eight  years,  which  in  place  of 
softening  and  breaking  down  have  been  undergoing  a  steady  fibroid 
change.  When  fistulae  are  formed,  usually  in  the  lower  posterior  part 
of  the  scrotum,  they  continue  to  discharge  a  thin  serous  fluid,  often  con- 
taining broken-down  granulations,  until  the  degenerated  tissue  is  en- 
tirely eliminated  ;  they  then  heal,  unless  there  is  extension  of  infiltration. 

Diagnosis. — The  diagnosis  of  acute  tubercular  epididymo-orchi- 
tis  is  based  on — (1)  The  apparently  causeless  outbreak  of  acute  in- 
flammation. When  traumatism,  mumps,  gonorrhoea,  syphilis,  and 
the  various  infectious  diseases  can  be  excluded,  tuberculosis  should 
be  suspected.  (2)  The  presence  of  tubercular  infiltration  in  the 
prostate  or  seminal  vesicles  or  evidences  of  infection  in  other  parts 
of  the  body.  (3)  Persistence  of  swelling  after  the  pain  and  other 
symptoms  of  acute  inflammation  have  subsided.  (4)  Formation  of 
nodules,  particularly  in  the  region  of  the  epididymes,  which  soften  and 
break  down,  leaving  fistulse,  in  the  discharge  of  which  may  be  found 
tubercle  bacilli. 

Acute  tubercular  epididymitis  commonly  develops  in  young  adults 
of  lymphatic  temperament  who  have  a  tubercular  family  history. 
The  pain  and  swelling  are  somewhat  less  marked  than  in  cases  of 
gonorrhoeal  epididymitis,  for  instance.  It  must  be  confessed  that  in 
the  first  one  or  two  weeks  of  an  attack  it  may  be  impossible  to  estab- 
lish a  diagnosis.  The  formation  of  suppurating  nodules  is,  however, 
characteristic.  The  cord  is  soon  involved,  becoming  thickened  and 
irregularly  bosselated. 


662  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

The  diagnosis  of  chronic  tubercular  epididymo-orchitis  is  based 
upon  a  tubercular  history,  the  painless,  non-inflammatory  development 
of  infiltration,  particularly  in  the  head  of  the  epididymis,  the  association 
with  non-gonorrhoeal  urethral  discharge,  frequent  urination,  and  haema- 
turia,  the  discovery  of  induration  or  nodulation  of  the  seminal  vesicles 
or  prostate,  the  gradual  extension  of  the  infiltration  to  the  entire  epi- 
didymis and  to  the  cord,  often  forming  an  irregular  tumor  much  larger 
than  the  testicle,  and  finally  upon  the  tuberculin  test  and  bacteriological 
examination.  When  there  is  an  associated  hydrocele  (and  this  is  com- 
mon), injection  of  this  fluid  into  the  peritoneal  cavity  of  rabbits  may  in 
tubercular  cases  cause  the  development  of  miliary  nodules.  The  ure- 
thral discharges  should  be  carefully  examined  for  tubercle  bacilli.  It 
must  be  remembered  that  it  is  possible  for  gonorrhoeal  epididymitis  to 
develop  and  run  its  typical  course  in  the  tubercular  subject  without 
subsequent  tubercular  infiltration  of  the  epididymis  or  testis. 

Differential  diagnosis  between  the  tubercular  nodule  and  the  indu- 
ration following  gonorrhoea  is  based  upon  the  history  of  a  preceding 
acute  urethritis  and  upon  the  fact  that  the  gonorrhoeal  induration  is 
found  in  the  tail  of  the  epididymis,  while  the  tubercular  nodule  is 
usually  in  the  head.  The  gonorrhoeal  nodule  exhibits  no  tendency 
towards  extension,  does  not  mask  the  outlines  of  the  epididymis,  and 
is  not  associated  with  palpable  lesions  of  the  cord  or  seminal  vesicles. 

The  diiferential  diagnosis  between  acute  gonorrhoeal  epididymitis 
and  acute  tubercular  epididymitis  in  the  absence  of  other  tubercular 
lesions  must  be  held  in  abeyance  until  the  tubercular  process  de- 
velops with  characteristic  features.  The  finding  of  the  gonococcus 
does  not  necessarily  exclude  tubercle. 

Prognosis.- — It  has  been  already  stated  that  tubercular  nodules 
may  become  encapsulated  and  absorbed,  leaving  a  mass  of  fibrous 
tissue  to  mark  their  position.  This  does  not  necessarily  indicate  that 
a  definite  cure  has  been  accomplished,  since  under  favoring  circum- 
stances the  tubercular  foci  may  again  become  active  and  with  greatly 
increased  virulence.  When  the  infection  is  located  only  in  the  epi- 
didymis or  testis,  spontaneous  cure  may  result  from  this  process  of 
encapsulation. 

The  course  of  the  case  will  be  unfavorable  in  direct  ratio  to  (1)  the 
rapidity  of  development ;  (2)  the  extent  of  involvement  of  the  gland ; 
(3)  the  tendency  to  become  bilateral ;  (4)  the  association  with  diffuse 
uro-genital  tuberculosis. 

In  any  event  it  cannot  be  too  strongly  emphasized  that,  as  in  all 
other  forms  of  surgical  tuberculosis,  the  prognosis  is  extremely  grave 
if  the  patient  is  necessarily  intrusted  to  the  vis  medicatrix  naturce. 


TUBERCULAR   DISEASE   OF    THE   TESTICLE.  663 

When  the  tubercular  process  is  lodged  solely  in  the  epididymis 
or  the  testicle  and  is  subjected  to  prompt  surgical  treatment,  the 
prognosis  is  extremely  favorable.  When  the  affection  is  bilateral, 
involving  the  cord,  seminal  vesicles,  and  prostate,  surgical  interven- 
tion promises  little  success ;  the  main  dependence  must  be  placed  on 
constitutional  hygienic  treatment. 

Treatment. — 1.  Palliative  Treatment. — When  a  patient  suffering  from 
tubercular  epididymo-orchitis  v^ill  not  submit  to  operation,  or  when 
the  disease  is  so  v^ide-spread  that  its  complete  removal  is  impossible, 
hygienic  measures  adapted  to  tubercular  patients  generally  are  indi- 
cated. The  most  efficient  of  these  is  probably  out-door  Hfe  in  a 
suitable  climate.  The  drugs  most  likely  to  be  of  use  in  this  class  of 
cases  are  cod-liver  oil,  syrup  of  ferric  iodide,  compound  syrup  of 
hypophosphites,  preparations  of  cinchona  and  kola,  whiskey,  and  beef 
peptonoids.  The  testicles  should  be  protected  and  supported  by  the 
pressure  suspensory  bandage  described  in  the  treatment  of  gonor- 
rhoeal  epididymis  or  by  a  well-fitting  jock-strap. 

2.  Radical  treatment.,  when  the  disease  is  strictly  localized, — i.e.., 
when  it  appears  in  the  form  of  small,  separate  nodules  or  foci  of 
caseation, — may  consist  in  incision,  followed  by  vigorous  scraping  of 
the  infected  tissues  and  packing  with  iodoform  gauze. 

Excision  of  the  epididymis  or  a  portion  of  the  testis  is  indicated 
when  there  is  reason  to  believe  that  a  considerable  part  of  the  gland 
may  be  safely  left.  An  incision  is  made  on  the  outer  posterior  scrotal 
surface  and  the  epididymis  is  out  away  from  below  upward,  the  blood- 
vessels lying  along  its  inner  border  being  spared.  If  the  vas  be  healthy, 
the  divided  end  is  split  for  one  centimetre,  and  this  broadened  open 
end  is  so  secured  over  the  rete  testis  that  the  continuity  of  the  seminal 
passage  is  secured. 

Injections  of  ten  per  cent,  emulsion  of  iodoform  in  glycerin  have 
given  excellent  results,  and  are  particularly  indicated  when  the  disease 
is  bilateral  and  cannot  be  eradicated  by  erosion  or  excision  of  the 
epididymis.  From  five  to  fifteen  drops  of  this  mixture  should  be 
employed  for  one  treatment,  and  should  be  driven  directly  into  the 
infiltrated  mass,  the  needle  being  introduced  at  several  points  and  two 
or  three  drops  being  deposited  at  each  point.  This  treatment  is  con- 
ducted under  antiseptic  precautions.  The  injections  are  repeated 
every  third  or  fourth  day,  depending  upon  the  violence  of  the  reaction. 

There  can  be  no  question  as  to  the  permanence  of  many  cures 
reported  from  the  injection  treatment,  though  as  a  result  the  epididy- 
mis becomes  hopelessly  obliterated. 

Castration  is  the   final  operation  applicable   to   advanced   cases. 


664  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

This  treatment  is  indicated  when  the  tuberculous  involvement  is  too 
extensive  to  be  removed  by  erosion  as  a  partial  operation,  and  when 
other  tuberculous  lesions  are  either  absent  or  but  moderate  in  extent. 

When  castration  is  performed,  not  only  the  testicle  but  all  infil- 
trated skin  and  cellular  tissue  should  be  removed.  The  cord  should 
be  divided  high  up,  and  the  vas  should  be  followed  beyond  the  limits 
of  nodulation  or  infiltration,  even  into  the  pelvis,  if  this  is  required  by 
the  extent  of  the  disease.  After  separation  and  ligation  of  the  vessels, 
by  making  traction  upon  the  vas  deferens,  which  would  come  out  in 
its  entire  length  without  risk  to  the  patient,  the  operation  may  be 
completed.  When  the  vas  is  infiltrated  through  its  entire  length, 
the  incision  for  castration  should  be  extended  from  the  scrotum 
upward  parallel  to  Poupart's  ligament  and  down  to  the  peritoneum, 
which  should  be  separated  from  the  lateral  walls  of  the  bladder 
by  the  finger,  using  the  vas  deferens  as  a  guide,  until  the  top  of  the 
seminal  vesicle  is  reached.  The  vas  is  divided  at  this  point  and 
extracted.  Roux  suggests  that  when  the  ampulla  of  the  vas,  the  pros- 
tate, and  the  seminal  vesicles  are  involved,  a  semilunar  incision  should 
be  made  in  front  of  the  anus,  the  rectum  separated  from  the  prostate, 
a  transverse  incision  made  in  the  fascia  covering  the  seminal  vesicles 
and  vasa,  and  the  diseased  structures  peeled  off  from  the  bladder  and 
removed.  Of  eleven  cases  thus  treated  by  Von  Biinger  eight  were 
free  from  recurrence  after  more  than  five  years ;  one  died  of  miliary 
tuberculosis. 

Haas  has  shown  that  double  castration  in  cases  of  tuberculosis  of 
the  testicle  is  followed  in  over  fifty  per  cent,  of  cases  by  radical  cure, 
and  does  not  cause  mental  or  nervous  disturbances.  Subsequent  to 
unilateral  castration  the  disease  appeared  in  the  remaining  testicle  in 
one-fourth  of  the  cases.  Following  any  operation  the  hygienic  and 
dietetic  treatment  appropriate  to  tuberculosis  should  be  continued  for 
a  long  time. 

Syphilis  of  the  testicle  and  epididymis  has  already  been 
described.  Scirrhous  and  gummatous  orchitis  are  frequent  manifes- 
tations of  constitutional  disease,  and  are  most  likely  to  develop  during 
the  period  of  life  when  sexual  activity  is  greatest.  They  may  begin 
insidiously  or  with  symptoms  of  acute  inflammation,  and  may  form 
nodules  at  the  head  of  the  epididymis,  or  may  attack  the  testicle  alone. 
The  tumor  formed  by  gummata  is  nearly  always  painless,  except  from 
its  weight.  This  infiltration  may  soften  and  break  down,  forming 
fistulas  or  fungus,  or  may  lead  to  atrophy  of  the  gland. 

The  diagnosis  of  syphilitic  epididymitis  from  the  tubercular  affec- 
tion is  based  on  the  density  and  sharper  demarcation  of  the  syphilitic 


TUMORS   OF  THE   TESTICLE.  g65 

nodules,  and  particularly  on  the  history  of  the  case  and  the  effect  of 
constitutional  treatment.  Acute  syphilitic  orchitis  is  characterized  by 
the  primary  development  of  the  affection  in  the  testis,  by  the  history 
of  syphilis,  by  the  absence  of  other  sufficient  cause  for  the  disease, 
and  by  the  effect  of  constitutional  treatment.  Gummatous  orchitis 
differs  from  tubercular  disease  in  forming  a  larger,  denser  tumor  before 
softening  occurs,  one  that  commonly  involves  the  entire  testis,  forming 
on  its  surface  ridges  or  nodules  and  never  reaching  the  size  of  a  man's 
fist  before  breaking  down.  It  is  commonly  masked  in  part  by  an  as- 
sociated hydrocele  and  is  often  bilateral.  Gummatous  fistulae  lead 
down  to  the  testicle  and  open  on  the  anterior  surface  of  the  scrotum, 
differing  in  both  these  respects  from  the  tubercular  fistulse.  The  diag- 
nosis between  syphilitic  and  tubercular  orchitis  may  be  impossible 
from  inspection  and  palpation.  The  distinction  of  syphilitic  sarcocele 
from  hsematoma  is  made  solely  on  the  history  of  the  development  of 
the  tumor  or  upon  the  result  of  aspiration. 

TUMORS   OF   THE    TESTICLE. 

An  elaborate  classification  of  tumors  of  the  testis,  such  as  is  given 
by  Monod  and  Terrillon,  is  of  Httle  practical  value.  For  clinical  pur- 
poses tumors  may  be  classed  as  malignant  and  benign.  The  tumors 
which  are  usually  malignant  include  carcinomata,  sarcomata,  cysto- 
mata,  lymphadenomata  (lymphosarcomata),  enchondromata,  myxo- 
mata,  and  mixed  tumors.  Tumors  usually  benign  are  fibromata, 
osteomata,  and  myomata. 

Oarcinonia. — Carcinoma  is  the  most  frequent  tumor  of  the  testis. 
Langhans  has  contributed  an  elaborate  histology  of  the  affection, 
based  on  a  study  of  thirty  cases.  The  tumor  may  be  of  a  soft 
(medullary)  or  hard  (scirrhous)  type.  Medullary  carcinoma  is  the 
more  frequent  form.  The  etiology  is  obscure,  but  is  often  traceable 
to  trauma;  the  disease  exhibits  a  special  predilection  for  undescended 
testes,  probably  because  these  are  so  frequently  subjected  to  repeated 
slight  injury.  Gonorrhoeal  epididymitis,  syphilis,  and  other  inflam- 
mations may  act  as  predisposing  causes.  Paget  states  that  cancer 
attacks  the  testicle  in  two  and  eight-tenths  per  cent,  of  all  cases  of 
malignant  disease.  The  disease  usually  develops  in  the  adult ;  excep- 
tionally it  attacks  the  testes  of  children. 

Kocher  teaches  that  the  tumor  usually  begins  in  the  centre  of 
the  testis,  though  it  may  originate  in  any  part  of  this  gland  or  in  the 
epididymis,  or  may  invade  both  structures  simultaneously ;  ulti- 
mately it  extends  along  the  cord.  Exceptionally,  malignant  infiltra- 
tion of  this  structure  may  develop  early,  in  the  course  of  the  lym- 


QQQ  GEISriTO-UKINAKY   DISEASES   AND    SYPHILIS. 

phatic  vessels.  The  scirrhous  tumors  are  much  smaller  than  the 
encephaloid,  rarely  reaching  the  size  of  a  fist.  In  both  forms  of  the 
affection  there  is  rapid  invasion  of  the  post-peritoneal  lymphatic 
glands,  with  further  upward  extension  to  those  of  the  mediastinum 
or  even  of  the  neck. 

Kocher  finds  tliat  more  than  one-half  the  cases  of  cancer  of  the 
testes  develop  between  the  thirtieth  and  the  fortieth  year.  Of  thirty- 
seven  cases,  twenty-eight  developed  between  the  twenty-fifth  and  the 
forty-fifth  year.  The  soft  tumor  usually  grows  rapidly,  sometimes 
attaining  the  dimensions  of  a  child's  head.  The  growth  in  the 
scirrhous  form  is  much  slower. 

The  tumor  usually  corresponds  to  the  form  of  the  testis  until  it 
has  thinned  or  perforated  the  albuginea,  when  it  becomes  irregular 
and  nodulated.  The  tunica  vaginalis  is  partly  obliterated  by  adhe- 
sions ;  the  portions  not  thus  closed  are  filled  with  blood-stained 
serum.  As  the  tumor  proliferates  it  may  involve  and  destroy  the 
skin,  forming  a  cauliflower-like  mass  of  bleeding  granulations  (fungus 
hsematodes). 

The  consistence  of  the  tumor  varies  greatly :  often  nodulations 
alternating  with  areas  of  softening  are  felt  through  its  substance ;  it 
may  exhibit  parenchymatous  hemorrhages  or  various  degenerations, 
as  mucoid  or  colloid. 

In  the  early  stages  the  epididymis  may  often  be  felt  entirely  unin- 
volved.  Later  it  becomes  infiltrated  and  indistinguishable  from  the 
mass  of  the  tumor.  Hydrocele  or  hsematocele  may  complicate  the 
affection  from  the  beginning  and  conceal  the  enlargement. 

The  swelling  often  develops  without  pain,  but  rarely  when  the 
growth  is  very  rapid ;  reflex  pains  are  usually  indicative  of  involve- 
ment of  the  cord  and  glands.  Testicular  sensation  is  lost  early.  The 
first  symptom  of  lymphatic  involvement  may  be  pains  referred  to  the 
inguinal  region  or  the  back,  or  along  the  course  of  the  sciatic  nerve, 
or  radiating  down  the  thighs.  The  enlarged  retroperitoneal  glands 
can  usually  be  felt  on  abdominal  palpation ;  by  pressure  upon  the 
veins  they  may  cause  oedema  of  the  legs.  The  inguinal  glands  are 
not  enlarged  until  the  scrotum  becomes  involved.  Cachexia  becomes 
marked  when  secondary  deposits  develop. 

Kocher  notes  that  in  malignant  tumors  of  the  testicle  the  vessels 
of  the  cord  become  extremely  large,  thus  differing  from  the  swelling 
caused  by  simple  hydrocele.  Moreover,  the  scrotal  veins  are  nearly 
always  dilated. 

Diagnosis. — The  early  detection  of  carcinoma  of  the  testis  is  of 
cardinal-  importance,  since  intervention  is  hopeless  unless  undertaken 


TUMOES   OF   THE    TESTICLE. 


667 


before  involvement  of  the  lymphatic  glands.  An  apparently  cause- 
less induration  of  the  testicle  followed  by  rapid  and  progressive  in- 
crease in  size  with  little  alteration  of  form  is  highly  indicative  of  ma- 
lignant growth,  especially  if  accompanied  by  marked  dilatation  of  the 
blood-vessels  of  the  cord  and  scrotum.  When  the  tumor  is  masked 
by  hydrocele,  the  latter  should  be  treated  by  open  incision,  thus  allow- 
ing the  testis  to  be  inspected  and  palpated. 

Malignant  growth  following  traumatism  may  be  distinguished  from 
traumatic  orchitis  only  by  the  progressive  increase  in  the  size  of  the 
testis.  When  the  cancer  is  thoroughly  developed  it  is  not  likely  to  be 
confounded  with  any  other  affection.     (Fig.  200.)     The  large  tumor, 

Fig.  200. 


Cancer  of  the  right  testicle.    (Monod  and  Terrillon.) 


the  infiltration  of  the  cord,  the  involvement  of  lymphatic  glands,  the 
discoloration  of  the  scrotum,  the  enlargement  of  the  blood-vessels, 
and  finally  the  cachexia,  are  all  characteristic.  Gumma  of  the  testicle 
never  grows  larger  than  the  size  of  the  fist,  and  does  not  enlarge  the 
glands.  Moreover,  it  is  sometimes  bilateral,  and  yields  to  specific 
treatment.  The  distinction  from  sarcoma  and  cystoma  cannot  be 
made. 

Haematocele  may  be  mistaken  for  malignant  disease.    There  should, 


668  GEJS^ITO-UEII^^AEY   DISEASES    AND   SYPHILIS. 

however,  be  a  history  either  of  trauma  with  a  growth  developing 
within  a  few  hours,  or  of  an  old  hydrocele  into  which  hemorrhage  may 
have  occurred.  In  hsematocele  pain  is  an  early  symptom,  and  the 
swelling  increases  intermittently  and  not  by  steady  growth  ;  it  is  less 
bossed  and  irregular  than  in  malignant  disease  ;  testicular  sensation 
is  not  so  completely  lost.  Tapping  may  establish  a  diagnosis,  though 
it  must  be  remembered  that  there  is  often  blood  effusion  into  the 
tunica  vaginalis  in  cases  of  malignant  disease. 

An  old  hydrocele  with  thickened  sac,  containing  fibro-cartilaginous 
material,  and  exhibiting  a  hard  and  uneven  surface,  may  resemble 
the  hard  form  of  the  malignant  disease.  When  it  is  impossible  to 
distinguish  between  these  two  affections,  an  early  incision,  followed 
by  an  operation  appropriate  to  the  condition  found,  is  advisable. 

Prognosis. — The  prognosis  of  carcinoma  of  the  testicle  is  bad,  par- 
ticularly when  the  retroperitoneal  glands  are  involved.  Paget  states 
that  the  duration  of  life  is  on  an  average  twenty-three  months,  patients 
living  about  six  months  after  operation,  since,  as  a  rule,  they  do  not 
consent  to  surgical  intervention  until  after  they  have  suffered  from  the 
disease  for  one  and  a  half  years.  Death  is  nearly  always  due  to 
metastasis.  The  scirrhous  form  of  the  disease  runs  a  slow  course : 
Nepveu  reports  one  case  which  survived  fifteen  years. 

A  few  cases  of  radical  cure  have  been  recorded.  Winiwarter,  of 
twelve  cases,  found  one  living  two  years  and  seven  months  after  oper- 
ation. Robin  and  Volkmann  report  four  cases  as  living  three  years. 
Kocher  publishes  the  records  of  six  cases ;  the  diagnosis  was  thor- 
oughly confirmed  by  microscopic  examination ;  two  were  well  one 
year  after  operation,  one  one  and  a  half  years,  one  four  and  a  half 
years,  one  eight  and  a  half  years,  one  ten  and  a  half  years ;  in  only 
one  instance  was  the  operation  performed  early. 

Treatment. — Early  castration  with  removal  of  as  much  of  the  cord 
as  possible  is  the  only  treatment  to  be  considered.  Any  enlarged  glands 
which  can  be  felt  should  be  removed  at  the  same  time  if  this  is  prac- 
ticable. These  glands,  when  they  attain  considerable  size,  are  densely 
adherent,  and  their  removal  is  extremely  difficult.  They  are  probably 
best  approached  through  the  peritoneal  cavity. 

Sarcoma. — This  may  appear  as  a  soft,  round-celled  tumor  or  as 
a  comparatively  hard,  spindle-celled  growth.  In  the  latter  case  the 
sarcoma  is  often  mixed  with  mucoid,  muscular,  or  cartilaginous  tis- 
sues (mixed  tumor).  The  distinction  between  sarcoma  and  carci- 
noma can  be  made  only  by  the  microscope ;  clinically  they  develop 
in  the  same  way,  and  they  are  equally  malignant.  The  sarcomata  are 
more  likely  to  have  associated  with  them  different  abnormal  tissues ; 


TUMORS   OF    THE    TESTICLE.  669 

the  presence  of  these  may  make  a  distinction  from  cancer  possible, 
the  latter  being  usually  a  uniform  growth.  Sarcoma  is  sometimes 
bilateral.  A  spindle-celled  sarcoma  is  somewhat  less  malignant  than 
carcinoma. 

The  symptoms  and  treatment  are  the  same  as  for  carcinoma. 

Cystoma. — Morris  states  that  cystic  disease  of  the  testicle  may 
become  manifest  in  the  form  of  a  number  of  minute  cysts  inter- 
spersed with  other  cysts  of  medium  size,  in  that  of  firm,  dense, 
fibrous  tissue  in  wdiich  are  numerous  cysts  of  varying  size,  or  in  that 
of  small,  unec{ually  distributed  cysts  placed  in  a  stroma  of  round- 
celled  sarcomatous  tissue. 

The  contents  of  cysts  may  be  clear,  mucoid,  or  like  coffee-grounds. 
Sometimes  they  contain  intracystic,  cauliflower-like  growths,  and  the 
stroma  in  which  they  are  placed  often  exhibits  areas  of  cartilaginous 
and  sarcomatous  degeneration.  The  disease  usually  begins  in  the 
mediastinum,  pushing  the  substance  of  the  testicle  upward  and 
forward. 

The  comparatively  benign  form  of  the  disease  may  last  for  many 
years,  forming  a  smooth  regular  tumor  of  moderate  size  rarely  larger 
than  the  fist,  which  may  exhibit  areas  of  fluctuation  or  may  seem  to 
be  uniformly  semi-soKd.  The  sarcomatous  cysts  grow  rapidly,  attain 
large  size,  and  become  bosselated. 

Cystic  chsease  develops  without  joain,  and  does  not  involve  the 
cord.  It  is  probable  that  the  fibrocystomata  may  be  benign,  but  they 
so  commonly  give  rise  to  metastasis  that  they  are  properly  classed  as 
malignant.     The  treatment  is  castration. 

Encysted  Hydrocele  of  the  Epididymis  and  Testis. — These 
affections  are  in  reality  cysts,  and  are  discussed  elsewhere.  (See  below.) 
In  this  affection  the  fluid  is  contained  in  distinct  cysts,  which  may  or 
may  not  project  into  the  cavity  of  the  vaginal  tunic  ;  this  tunic,  or  at 
least  its  parietal  layer,  does  not  form  the  walls  of  the  cysts.  These 
cysts  may  originate  in  the  epididymis,  in  fostal  structures  lying  near 
by,  or  in  the  testicle.  (Fig.  201.)  They  may  contain  a  milky  fluid, 
which  under  the  microscope  is  found  to  be  filled  with  spermatozoa 
(this  is  particularly  true  of  the  larger  cysts),  or  their  contents  may  be 
perfectly  translucent,  but  differing  markedly  from  hydrocele  in  com- 
position, since  they  contain  little  or  no  albumen. 

Cysts  of  the  Epididymis. — These  cysts  may  be  small  or  large ;  the 
small  cysts  are  usually  multiple,  and,  according  to  Gosselin,  develop 
in  the  majority  of  testes  after  middle  life.  They  may  be  very  minute 
or  as  large  as  a  pea,  and  are  sometimes  pedunculated.  They  are 
easily  shelled  out  from  the  surrounding  tissue.     Exceptionally  they 


670 


GENITO-UEINART   DISEASES   AND   SYPHILIS. 


contain  spermatozoa.  They  are  placed  both  on  the  surface  and  in  the 
parenchyma  of  the  epididymis.  They  may  develop  from  the  rem- 
nants of  foetal  structure;  more  probably  they  are  involution  cjsts, 
originating  in  the  tissue  of  the  epididymis,  but  becoming  subserous. 


Fig.  201. 


Intravaginal  spermatocele.    (Hochene; 


The  large  cysts  are  parenchymatous,  arising  beneath  the  outer 
covering  of  the  epididymis  and  close  to  its  upper  part,  or  between  it 
and  the  upper  part  of  the  testicle.  (Fig.  202.)  They  he  outside  of 
the  visceral  layer  of  the  vaginal  tunic,  pushing  this  upward  as  they 
become  distended,  and  are  in  close  contact  with  the  seminal  ducts. 
They  are  usually  single,  but  may  be  multiple  or  multilocular.  Com- 
monly the  fluid  is  milky  from  the  spermatozoa  which  it  contains, 
though  it  may  be  hmpid.  These  cysts  may  arise  either  from  retention 
cysts  or  from  the  development  of  the  foetal  remains.  Spermatozoa 
may  find  their  entrance  into  them  through  minute  openings,  difficult 
to  recognize  at  any  time,  and  capable  of  closing  long  before  the  cyst 
is  examined.  They  rarely  attain  great  dimensions,  containing  on  an 
average  not  more  than  two  or  three  ounces  of  fluid.  Exceptionally 
they  may  form  large  tumors.  (Fig.  203.)  They  are  not  confined  to 
old  age,  developing  at  any  time  after  full  sexual  maturity. 

Morris  states  that  the  cyst  may  originate  as  a  retention  cyst  due 
to  dilatation  of  a  seminal  tube,  owing  to  some  obstruction  in  the  vas 
deferens  or  other  part  of  the  excretory  passages  (Liston,  Luschka, 
and  others) ;  or  as  a  new  formation  in  the  connective  tissue  between 
the  tubes  of  the  epididymis  subsequent  upon  the  rupture  of  a 
seminal  tubule  and  the  escape  of  some  drops  of  seminal  fluid.  The 
opening  in  the  duct  may  afterwards  cicatrize,  so  that  there  need  not 
persist  a  communication  between  the  duct  and  the  new-formed  cyst. 


TUMOES    OF    THE   TESTICLE. 


e7i 


The  cyst  may  be  formed  originally  in  the  connective  tissue,  and 
by  gradually  enlarging  may  cause  subsequently  the  rupture  of  a  sem- 
inal tubule,  and  thus  the  entrance  into  the  cyst  of  spermatozoa.  (Cur- 
ling.) The  cysts  may  arise  from  the  distention  of  certain  foetal  relics 
which  exist  in  the  neighborhood  of  the  epididymis,  especially  near 
the  globus  major. 

The  fcetal  structures  from  which  cysts  of  the  epididymis  originate 
are — (1)  The  paradidymis,  or  organ  of  Giraldes,  a  minute  body,  the 


Fig.  202. 


Fig.  203. 


T-4 


Encysted  hydrocele  (large  cysts). 


Multlloeular  cyst  of  the  epididymis.  T,  tes- 
ticle ;  E,  epididymis  displaced  by  the  cyst. 
(Mouod  and  Terrillon.) 


remnant  of  the  mesonephros  or  glandular  portion  of  the  Wolffian 
body.  This  is  situated  in  front  of  the  lower  part  of  the  vas  and  above 
the  head  of  the  epididymis  and  behind  the  upper  part  of  the  tunica 
vaginalis.  Cysts  having  this  origin  are  situated  above  the  testis  and 
epididymis,  and  extend  sometimes  a  little  way  along  the  cord.  They 
correspond  to  paroophoritic  cysts  in  the  female.     (2)  The  ducts  of 


^72  GENITO-TJEINAKY   DISEASES   AND   SYPHILIS. 

Kobelt,  which  are  remnants  of  the  tubules  of  the  Wolffian  body,  sit- 
uated in  the  globus  major.  (3)  The  vestiges  of  the  duct  of  Muller, 
part  of  which  is  represented  by  the  hydatid  of  Morgagni,  can  sometimes 
be  traced  from  the  globus  major  down  to  the  globus  minor,  along  the 
body  of  the  epididymis  in  the  digital  pouch.  Cysts  derived  from  these 
sources  are  situated  between  the  epididymis  and  testis,  most  frequently 
between  the  globus  major  and  the  upper  end  of  the  testis.  Those 
derived  from  the  vasa  efferentia  and  other  remnants  of  the  Wolffian 
tubules  are  homologous  with  parovarian  cysts  in  the  female,  (4)  The 
vas  aberrans  of  Haller,  which  is  a  diverticulum  of,  or  a  convoluted 
caecal  tube  opening  into,  the  vas  deferens  close  to  the  lower  end  of  the 
epididymis  ;  this  also  is  a  part  of  the  remains  of  one  of  the  tubes  of 
the  Wolffian  body  still  in  connection  with  the  representative  of  the 
excretory  duct  of  that  body, — namely,  the  vas  deferens. 

Cysts  of  the  Testis.—  These  grow  in  front  of  the  gland  between 
the  tunica  albuginea  of  the  testis  and  the  testicular  portion  of  the 
tunica  vaginalis.  They  are  usually  of  small  size,  and  from  intracystic 
tension  feel  like  a  hard  body. 

Symptoms  of  cysts  of  the  epididymis  and  testis  are  slow  in  devel- 
oping, though  exceptionally,  from  traumatic  rupture  of  a  cyst  into 
the  cavity  of  the  vaginal  tunic,  there  may  be  swelling  and  pain  char- 
acteristic of  acute  hydrocele.  Small  cysts,  particularly  those  of  the 
epididymis,  are  recognized  with  difficulty  even  after  careful  palpation. 
As  they  increase  in  size  they  form  distinct  fluctuating  tumors,  which, 
if  the  fluid  is  clear,  will  give  the  test  of  transmitted  light.  These  cysts 
have  often  been  mistaken  for  supernumerary  testicles,  or,  because  of 
tension  and  consequent  hardness,  for  tubercular  infiltration  of  the 
epididymis.     They  seldom  reach  large  size. 

Diagnosis  is  founded  upon  translucency  when  the  fluid  contained 
in  the  cyst  is  limpid.  Thrill,  fluctuation,  want  of  density  and  resist- 
ance, and  slowness  in  development  distinguish  these  cysts  from 
ordinary  sarcoceles.  In  shape  they  are  globular  when  small,  but  if 
large  and  multilocular  the  shape  varies  greatly.  By  transmitted  light 
the  testicle  is  usually  seen  lying  below  and  in  front  of  the  tumor, 
although  it  may  be  to  one  or  the  other  side,  more  frequently  the 
inner.  On  palpation  it  is  often  possible  to  determine  that  the  enlarge- 
ment is  absolutely  limited  to  the  upper  portion  of  the  testis  and  epi- 
didymis, and  has  a  tendency  to  extend  upward  along  the  cord,  the 
testis  proper  being  perfectly  normal  and  the  tunica  vaginalis  contain- 
ing no  fluid.  At  times  exploratory  puncture  with  a  hypodermic  needle 
will  be  necessary  before  a  diagnosis  can  be  established.  The  fluid  ob- 
tained will  be  found  swarming  with  spermatozoa. 


TUMORS   OF   THE    TESTICLE.  g73 

Treatment. — These  cysts  grow  so  slowly  and  cause  so  few  symp- 
toms that  intervention  is  often  not  necessary.  Evacuation  by  means 
of  an  aspirator  or  a  small  trocar  and  canula  may  be  followed  by  cure. 
If  this  fails,  iodine  may  be  injected,  as  described  in  the  treatment 
of  hydrocele,  or  the  scrotum  may  be  opened  and  the  cyst  dissected 
out.  The  operation  of  excision  is  particularly  indicated  when  the 
cysts  are  multiple  or  multilocular.  When  complete  excision  is  im- 
possible without  extensively  injuring  the  structure  of  the  testicle 
or  epididymis,  the  cyst-wall  should  be  removed  as  thoroughly  as  pos- 
sible, and  the  remaining  portion  should  be  cauterized  with  carbolic 
acid. 

Enchondroma  originates  in  the  interstitial  connective  tissue  of 
the  rete  testis  ;  it  is  commonly  found  between  the  thirtieth  and  the 
fortieth  year  of  life.  It  is  rare  in  children  and  unknown  in  old  age. 
The  development  of  the  tumor  is  as  symptomless  as  that  of  carci- 
noma. There  forms  a  hard,  gradually  growing  mass,  which  causes 
inconvenience  only  by  its  weight.  After  growing  slowly  for  some  time 
there  may  be  a  sudden  increase  in  the  rate  of  development,  often 
characterized  by  the  appearance  of  soft,  fluctuating  spots  in  the  dense 
tumor.     Ultimately  enchondromata  undergo  metastasis. 

The  enchondromata  may  be  simple  or  mixed. 

Simple  enchondroma  is  extremely  rare.  A  smaH,  dense  tumor 
appears  not  larger  than  a  walnut,  and  persists,  without  increase  in 
size,  for  many  months  or  even  for  several  years.  The  epididymis  and 
cord  are  not  affected  until  the  late  stage  of  the  disease.  After  a  long 
period  of  inactivity  there  may  be  rather  rapid  growth,  in  which  case 
the  enlargement  becomes  irregularly  lobulated  and  is  extremely 
dense. 

Mixed  enchondroma  contains  between  the  cartilaginous  masses  sar- 
comatous tissue.  It  is  more  rapid  in  its  course,  grows  to  a  larger  size, 
more  commonly  exhibits  areas  of  softening,  and  invades  the  cord. 

Diagnosis. — The  diagnosis  is  founded  upon  the  density  and  nodu- 
lation  of  the  growth,  its  comparatively  slow  development,  the  absence 
of  pain,  and  the  ultimate  dissemination.  Soft  or  fluctuating  areas 
suggest  a  mixed  tumor  and  therefore  the  more  malignant  form  of 
enchondroma,  though  tumors  made  up  entirely  of  cartilage  give 
metastasis. 

Treatment. — Early  castration  is  the  only  treatment  to  be  considered. 

Lymphadenonia  is  a  rare  affection,  which  can  be  positively 
distinguished  from  other  malignant  sarcoceles  only  by  microscopic 
examination.  It  does  not  reach  the  size  of  sarcoma  or  carcinoma, 
Is  not  prone  to  ulcerate  or  to  cause  hydrocele,  does  not  infiltrate  the 

43 


674 


GENITO-UKINAKY    DISEASES    AND    SYPHILIS. 


epididymis,  and  causes  a  symmetrical  enlargement  of  the  gland.  It 
is  often  bilateral,  and  sometimes  is  associated  with  lymphadenoma 
in  other  portions  of  the  body.  It  develops  in  the  testes  of  young 
men.     (Fig.  204.) 

Fibroma  of  the  testicle  is  extremely  rare.  It  develops  as  a  hard, 
painless  tumor,  springing  apparently  from  the  proper  tunic  of  the  tes- 
ticle, and  producing  pressure  atrophy  of  the  gland.  Neither  the  cord 
nor  the  epididymis  is  involved,  and  hydrocele  does  not  develop.  It 
occurs  in  early  manhood,  and  may  be  bilateral. 

The  diagnosis  is  made  from  the  hardness  of  the  tumor,  the  absence 
of  involvement  of  the  cord  and  the  epididymis,  the  slowness  of  de- 
velopment, and  the  preservation  of  testicular  sensation. 

The  treatment  is  excision. 

Dermoid  Cysts. — Dermoid  cysts,  or  teratomata,  are  congenital 

Fig.  204. 


Lymphadenoma  of  the  testicle  (bilateral). 


growths,  containing  hair,  skin,  sebaceous  material,  bone,  teeth,  or 
portions  of  other  organs.  The  tumor  may  be  found  in  the  testis  or 
entirely  outside  of  it.  It  is  usually  adherent  to  it,  and  placed  between 
the  testis  and  the  epididymis,  or  in  front  of  the  testicle.  These  tumors 
may  remain  stationary,  may  grow  rapidly,  or  may  suppurate. 

Diagnosis  can  be  made  positively  only  by  an  examination  of  the 


CASTKATION.  (375 

contents  of  the  cyst.  The  fact  that  the  tumor  is  congenital  suggests 
its  nature.  It  may  remain  quiescent  until  puberty  or  between  the 
twentieth  and  the  thirtieth  year.  Commonly  it  develops  in  the  first 
few  months  of  life. 

Verneuil  states  that  there  is  often  a  period  of  stagnation,  during 
which  the  tumor  grows  in  proportion  to  the  general  development. 
This  is  followed  by  an  inflammatory  period,  during  which  there  is 
rapid  growth.  This  may  not  occur  for  many  years.  When  the  tumor 
grows  slowly  it  may  reach  large  size  without  causing  any  symptoms 
aside  from  its  weight.  The  size  of  the  tumor  may  be  enormous.  It 
may  be  as  hard  as  an  enchondroma  or  soft  and  fluctuating. 

Myxoma,  osteoma,  and  myoma  are  surgical  rarities  which 
need  no  detailed  description.  Indeed,  these  tumors  have  been  so 
seldom  observed  that  their  symptomatology  and  clinical  course  can- 
not be  formulated.  They  are  mainly  important  because  they  ob- 
scure the  diagnosis  of  malignant  growth.  It  is  impossible,  for  in- 
stance, to  distinguish  osteoma  from  enchondroma  except  by  the  test 
of  time. 

CASTRATION. 

This  operation,  indicated  when  the  diagnosis  of  malignant  disease 
is  confirmed,  would  probably  be  attended  with  a  large  percentage  of 
radical  cures  were  it  undertaken  in  the  early  stages  of  infiltration. 
During  this  period  it  is  impossible  to  formulate  the  diagnosis. 

When  tubercle  or  syphilis,  or  sufficient  cause  for  acute  or  chronic 
inflammation  of  the  testis,  can  be  excluded,  we  believe  enlargement 
of  this  gland  should  be  subjected  to  exploratory  incision,  followed  by  ■ 
immediate  castration  if  there  is  reason  to  suspect  malignant  growth, 
or  by  microscopic  examination  of  excised  tissue  in  case  palpation  and 
direct  inspection  lead  the  surgeon  to  beheve  that  the  induration  is 
probably  not  malignant.  The  exploratory  incision  is  in  itself  harm- 
less, and  even  when  the  diagnosis  is  apparently  well  assured  should 
precede  castration.  We  have  seen  a  haematocele  with  walls  two 
inches  thick,  and  containing  cartilaginous  nodules,  develop  abso- 
lutely according  to  the  type  of  malignant  growth,  with  the  exception 
of  glandular  involvement.  Prehminary  incision  would  in  such  a  case 
be  the  means  of  saving  a  comparatively  healthy  testicle.  If  on  ex- 
ploratory excision  either  a  solid  tumor  or  cystic  degeneration  is  found, 
syphihs  and  tuberculosis  having  been  excluded,  the  chances  are  largely 
in  favor  of  its  malignancy. 

Castration  is  attended  with  little  danger.  Kocher  reports  but  one 
death  in  twenty-three  cases  operated  on.  This  death  was  due  to 
pyaemia.     The  shock  of  which  so  much  has  been  written  we  have 


676  GENITO-UKIl^AEY   DISEASES   AND    SYPHILIS. 

never  seen,  even  when  removing  comparatively  healthy  testicles.  It 
is  still  less  likely  to  occur  when  the  testicular  substance  has  been 
destroyed  by  infiltration. 

Preliminary  cleansing  of  the  operative  region  should  be  repeated 
several  times,  at  intervals  of  some  hours,  and  immediately  before 
operation  the  penis  should  be  tightly  bandaged  in  sterile  gauze, 
since  it  is  a  frequent  source  of  infection  in  operations  about  the 
genitalia. 

The  incision  varies  in  accordance  with  the  conditions.  When  the 
tumor  is  small  and  non-adherent  and  the  cord  is  not  involved,  an 
opening  over  the  external  abdominal  ring  large  enough  to  allow  the 
tumor  to  be  pulled  out  suffices.  If  the  growth  is  large,  adherent,  and 
extending  up  the  cord,  the  incision  should  be  so  planned  that  all  the 
adherent  skin  will  be  removed,  and  should  run  parallel  with  Poupart's 
ligament,  half  an  inch  above  it,  to  the  position  of  the  internal  ring. 
The  incision  should  be  made  layer  by  layer,  as  this  enables  the  oper- 
ator to  judge  of  the  amount  of  integument  involved  and  to  decide  on 
the  extent  of  interference  required.  The  incision  should  go  wide  of 
diseased  tissue,  the  vaginal  tunic  and  the  greater  part  of  the  scrotal 
tissues  of  the  affected  side  being  taken  with  the  growth. 

Bleeding  is  checked  by  liEeinostatic  forceps ;  the  testicle  is  freed 
from  its  surroundings  and  drawn  well  down,  while  a  fmger  passed  up 
along  the  cord  determines  its  position  and  acts  as  a  director  to  open 
the  inguinal  canal  as  far  as  may  be  necessary. 

The  cord  is  isolated  above  the  point  of  perceptible  involvement, 
drawn  well  down,  transfixed  with  a  gut  ligature,  tied  in  two  portions, 
cut  across  below  the  seat  of  ligation,  and  the  lumen  of  the  vas  cauter- 
ized with  pure  carbohc  acid. 

If  the  vascular  constituents  of  the  cord  are  ligated  separately,  three 
arteries — the  cremasteric,  the  spermatic,  and  the  deferential — must  be 
tied.  The  deferential  artery  is  found  close  to  the  vas,  and  with  it  are 
a  few  veins ;  the  cremasteric  lies  to  the  outer  side  of  the  cord,  near 
its  surface ;  the  spermatic  is  in  front  of  the  cord,  surrounded  by  the 
anterior  group  of  veins,  and  can  scarcely  be  distinguished  from  them. 
Each  artery  should  have  a  separate  ligature,  but  the  two  sets  of  veins 
may  be  tied  en  masse  j  the  divided  cord  should  be  secured  with  artery 
forceps  until  the  end  of  the  operation.  The  bleeding  from  the  scrotal 
tissues  is  controlled  by  forcipressure  or  ligatures,  and  redundant  por- 
tions of  the  scrotum,  particularly  those  which  may  be  infiltrated,  are 
removed.  The  edges  of  the  wound  are  then  carefully  approximated, 
care  being  taken  to  prevent  inversion  by  the  dartos.  The  sutures 
should  be  of  silk,  and  the  last  one  may  secure  a  drainage-tube  in 


HYDKOCELE.  677 

the  lower  angle  of  the  wound  if  the  case  has  been  an  infected  one. 
Otherwise  drainage  is  unnecessary. 

An  antiseptic  dressing  is  apphed  and  held  in  place  by  the  crossed 
of  the  perineum. 

The  patient  may  sometimes  complain  of  retention  of  urine,  last- 
ing from  twenty-four  to  thirty-six  hours.  This  is  best  relieved  by 
enemata  of  hot  saline  solution.  Should  this  fail,  the  catheter  may  be 
used.     The  stitches  are  removed  on  the  fifth  to  the  seventh  day. 

When  the  cord  is  extensively  involved,  the  incision  should  be 
extended  up  along  Pouparfs  ligament,  as  already  described.  It  is 
deepened  to  the  peritoneum,  which  is  stripped  up,  allowing  access  to 
the  glands  of  the  pelvis.  When  the  lymphatic  involvement  extends 
upward  beyond  reach  it  may  be  attacked  through  a  transperitoneal 
opening.  The  glands  into  which  the  vessels  of  the  cord  pass  com- 
pletely surround  the  aorta.  There  is,  moreover,  one  lying  upon  the 
external  iliac  artery  which  probably  will  be  involved. 

HYDROCELE. 

Hydrocele  is  a  condition  in  which  there  is  an  abnormal  amount 
of  fluid  about  the  testis  or  the  cord,  limited  by  the  tunica  vaginalis. 
Hydrocele,  without  further  qualifying  words,  as  "  encysted"  or  "  of 
the  cord,"  indicates  a  serous  effusion  between  the  two  layers  of  the 
tunica  vaginalis  testis. 

Prolongations  of  peritoneum,  called  the  vaginal  processes,  precede 
the  testicles  in  their  descent  into  the  scrotum,  thus  forming  a  pouch, 
into  which  the  testicle  with  its  epididymis  is  invaginated.  The  funicu- 
lar portion  of  this  pouch  usually  becomes  obliterated  from  the  inter- 
nal abdominal  ring  to  a  point  just  above  the  testis,  leaving  a  serous 
sac  enveloping  this  organ,  in  which  is  normally  found  just  enough 
fluid  to  allow  its  surfaces  to  glide  smoothly  over  each  other. 

The  invagination  of  the  testicle  into  the  peritoneal  pouch  neces- 
sarily forms  a  parietal  and  a  visceral  portion.  The  parietal  portion 
forms  a  loose  investment,  extending  above  and  below  the  testis,  and 
connected  by  cellular  tissue  to  the  surrounding  structures  of  the  scro- 
tum. The  visceral  portion  invests  the  testis  and  the  epididymis,  con- 
necting these  structures,  and  forming  a  fossa  or  pouch  between  them 
(digital  fossa).  At  the  posterior  portion  of  the  gland  it  becomes  con- 
tinuous with  the  parietal  layer.  The  tail  of  the  epididymis  is  not 
included  in  the  double  serous  envelope,  since  the  reflection  of  the 
visceral  layer  is  upon  the  front  and  sides  of  the  scrotal  ligament  of 
the  testicle,  a  fibro-muscular  band  passing  from  the  lower  posterior 
portion  of  the  testis  and  the  tail  of  the  epididymis  to  the  dartos. 


678  GENITO-UEINAKi    DISEASES   AND    SYPHILIS. 

ACUTE   HYDROCELE. 

This  affection,  an  acute  vaginalitis,  is  usually  due  to  extension 
of  acute  inflammation  from  the  epididymis.  It  is  also  secondary  to 
orchitis,  and  may  be  caused  by  traumatism  or  irritating  injections. 

It  is  probable  that  in  every  case  of  epididymitis  there  is  some 
extension  of  inflammation  to  the  tunica  vaginalis,  and  that  the  acute 
effusions  which  complicate  infectious  diseases  or  catheter  urethritis 
are  secondary  to  epididymitis  or  orchitis. 

The  pathological  changes  in  the  tunica  vaginalis  are  essentially  the 
same  as  those  occurring  in  acute  inflammations  of  serous  mem'branes 
in  other  parts  of  the  body. 

The  effusion  may  be  serous  or  fibrinous.  Serous  effusion,  though 
common,  is  not  often  examined  clinically,  since  it  is  slight,  transitory, 
and  indicative  of  a  mild  inflammation.  Plastic  effusion  does  not  differ 
from  ordinary  inflammatory  lymph.     Suppuration  is  extremely  rare. 

Symptoms. — The  symptoms  of  acute  hydrocele  are  masked  by  those 
of  the  primary  disease.  Thus,  in  gonorrhoeal  epididymitis  the  usually 
moderate  amount  of  effusion  into  the  vaginal  tunic  is  obscured  by  the 
oederaatous  swelhng  of  the  entire  scrotum.  If  effusion  is  abundant  it 
will  form  a  tense,  rounded  or  pyriform,  fluctuating  tumor  which  is 
translucent  and  which  feels  like  a  greatly  enlarged  testicle. 

The  pain  attending  acute  hydrocele  is  sometimes  extremely  severe, 
corresponding  in  type  precisely  to  that  of  gonorrhceal  epididymitis. 
This  pain  is  doubtless  due  to  tension,  since  puncture  affords  almost 
immediate  relief.  In  addition  to  pain  and  swelling  there  are  present 
heat,  redness,  and  scrotal  cedema.  The  general  constitutional  symp- 
toms are,  as  a  rule,  slight. 

Diagnosis. — The  most  important  single  diagnostic  sign  is  trans- 
lucency.  This  symptom  may  be  best  elicited  by  the  employment  of 
a  tube  about  half  an  inch  in  diameter ;  an  ordinary  stethoscope  will 
answer.  One  end  of  this  tube  is  applied  to  the  scrotum,  the  examiner 
looking  through  the  other  end  while  a  bright  light  is  held  close  to 
the  opposite  side  of  the  tumor.  The  method  of  examining  the 
scrotum  by  making  the  overlying  tissues  tense  by  pressure  is  not 
applicable  to  an  acute  hydrocele,  because  of  the  pain  this  manipu- 
lation excites.  Another  method  of  eliciting  translucency  is  to  place 
against  the  scrotum  the  open  end  of  a  shallow  cup  in  which  is  an 
electric  light.  Examinations  for  transmitted  light  must  be  conducted 
in  a  dark  room.  In  case  the  fluid  is  mixed  with  blood,  this  test  wfll 
be  inconclusive.  The  aspirating  needle  will  then  prove  serviceable, 
though  before  employing  this  instrument  the  surgeon  should  be  sure 


ACUTE   HYDEOCELE.  679 

that  he  is  not  dealing  with  strangulated  hernia.  On  the  subsidence 
of  acute  inflammation  the  diagnosis  can  be  made  without  difficulty 
by  determining  the  presence  of  fluid.  This  test  is  made  by  seizing 
the  scrotum  in  the  left  hand  and  making  the  skin  over  the  swelling 
moderately  tense.  Then,  by  sudden  pressure  with  the  finger  of 
the  right  hand,  the  sensation  of  liquid  being  pressed  aside  will  be 
noted  before  the  comparatively  firm  resistance  of  the  testicle  is 
felt ;  or  by  the  alternate  pressure  of  the  two  hands  fluctuation  will 
be  detected.  When  inflammation  has  still  further  subsided,  the 
presence  or  absence  of  fibrinous  deposits  may  be  determined  by 
seizing  the  testicle  in  front  and  pressing  it  backward  from  between 
the  thumb  and  fingers.  Ordinarily  it  readily  slips  back,  leaving  in 
the  grasp  the  scrotal  tissue  and  the  external  layer  of  the  vaginal 
tunic.  If  the  parietal  and  visceral  layers  of  the  vaginal  tunic  are 
adherent,  the  testicle  will  not  slip  back  from  the  grasp  in  this  way, 
or,  if  it  does,  will  leave  a  thickened  mass  between  the  thumb  and 
fingers. 

Examination  on  the  subsidence  of  inflammation  will  generally 
show  thickening  and  induration  of  the  epididymis. 

Double  hydrocele  is  usually  accompanied  by  sterility,  another 
proof  of  the  almost  invariable  association  of  this  affection  with  epi- 
didymitis. 

Prognosis. — Acute  hydrocele  ma}  undergo  resolution ;  the  plastic 
deposit  may  organize  partially  or  completely,  obliterating  the  cavity 
of  the  tunica  vaginalis  ;  the  inflammation  may  become  chronic,  con- 
stituting the  ordinary  form  of  hydrocele,  and  in  this  case  organization 
of  the  fibrinous  tissue  often  divides  the  general  cavity  into  secondary 
ones,  distinctly  separated  from  one  another ;  or,  finally,  suppuration 
may  take  place. 

Treatment. — Acute  hydrocele  is  treated  in  accordance  with  general 
surgical  principles :  rest  in  bed,  elevation  of  the  part,  the  employ- 
ment of  evaporating  lotions,  such  as  equal  parts  of  lead  water  and 
alcohol,  or  a  counterirritant  in  the  form  of  twenty  per  cent,  guaiacol 
ointment  are  useful.  The  bowels  should  be  purged  with  salines,  and 
the  diet  carefully  regulated.  Pelvic  congestion  must  be  avoided. 
Later,  pressure  by  the  suspensory  bandage,  with  the  application  of 
mild  absorbent  ointments,  are  indicated.  The  best  of  these  is  the 
official  mercury  and  belladonna  ointment  of  the  U.  S.  P.  If  the  pain 
becomes  unbearaJDle,  it  may  be  relieved  at  once  by  puncture,  as  in  the 
case  of  gonorrhoeal  epididymitis. 

If  the  effusion  is  not  absorbed  in  six  weeks,  treatment  appropriate 
to  chronic  hydrocele  is  undertaken. 


680 


GENITO-UEINAEY    DISEASES   AND   SYPHILIS. 


(a)  Hydrocele  of  Tunica 
Vaginalis.  —  The 
fluid  is  in  a  sac 
connected  with 
tliat  of  the  tunica 
vasinalis. 


CHRONIC   HYDROCELE. 
Jacobson  thus  classifies  chronic  hydrocele 


1.  Ordinary  Hydrocele. — The  fluid  distends 
the  closed  sac  of  the  tunica  vaginalis. 

2.  Congenitcd  Hydrocele. — A  communication 
exists  between  the  cavity  of  the  tunica 
vaginalis  and  that  of  the  peritoneum. 

3.  Infantile  Hydrocele. — The  tunica  vagi- 
nalis and  the  funicular  process  are  dis- 
tended with  fluid,  but  these  are  shut 
off  from  the  peritoneal  cavity  by  an 
obliteration  placed  usually  at  the  ex- 
ternal ring. 

4.  Inguinal  Hydrocele. — Hydrocele  in  rela- 
tion with  a  retained  testis. 

1.  Encysted  Hydrocele  of  the  Epididymis. — 
The  fluid  is  encysted  in  the  neighbor- 
hood of  the  epididymis. 

2.  Encysted  Hydrocele  of  the  Testis. — The 
fluid  is  encyst^  between  the  tunica 
albuginea  and  the  inner  surface  of  the 

I  tunica  vaginalis. 

(o)  Diffused. — The  fluid  forms  a  serous  collection  of  the  nature  of 
oedema  in  the  cellular  tissue  of  the  cord. 

(;3)  Encysted. — The  fluid  is  contained  in  a  distinct  sac  originating 
usually  (1)  in  some  unobliterated  part  of  the  processus  funiculo- 
vaginalis  ;  (2)  in  a  cyst  formed  independently  of  this  process, — 
e.g.,  by  dilatation  of  persistent  tubules  of  the  organ  of  Giraldes. 

(a)  With  other  Coexisting  Hydroceles. — E.g.,  (1)  hydrocele  of  the 
tunica  vaginalis  with  encysted  hydrocele  of  the  testis  ;  (2)  hydro- 
cele of  the  tunica  vaginalis  with  encysted  hydrocele  of  the  cord ; 
(3)  hydrocele  of  the  tunica  vaginalis  with  diffused  hydrocele 
of  the  cord. 

(3)  With  Hernia. — E.g.,  (1)  hydrocele  of  the  tunica  vaginalis  with 
inguinal    hernia ;    (2)    hydrocele   of    the    cord   with    inguinal 
hernia. 
IV.  Hydrocele  of  the  sac  of  a  hernia. 


(3)  Encysted  Hydrocele. 
— The  fluid  is  in  a 
sac  distinct  from 
that  of  the  tunica 
vaginalis. 


Hydrocele  of  the  Tunica  Vaginalis  Testis. — (Fig.  205.)  This, 
the  ordinary  form  of  hydrocele,  is  in  the  majority  of  cases  secondary 
to  pathological  conditions  of  the  epididymis,  testicle,  or  cord.  It  is 
particularly  associated  with  disease  of  the  epididymis. 

Loose  cartilaginous  bodies  are  sometimes,  but  rarely,  found  within 
the  sac,  and  may  by  their  continued  irritation  give  rise  to  an  abnor- 
mal secretion  of  fluid.  Hydrocele  may  be  due  to  passive  exudation 
caused  by  an  obstruction  to  the  return  of  circulation.     This  exudation 


CHKONIC   HYDKOCELE. 


681 


may  be  caused  by  an  ill-fitting  truss,  by  the  presence  of  filariae,  or  by 
hepatic  or  renal  disease.  The  frequent  occurrence  of  hydrocele  in 
warm  climates  and  in  persons  suffering  from  malaria  is  due  to  asso- 
ciated hepatic  enlargements.  In  general  dropsy  the  scrotal  tissues 
may  be  oedematous,  but  fluid  in  the  tunica  vaginalis  is  seldom  or 
never  found. 

A  certain  number  of  cases  seem  to  be  idiopathic, — i.e.^  there  is  no 
discoverable  preceding  inflammation  of  the  scrotal  contents. 

Fig.  205. 


Vertical  section  of  hydrocele.    (Kocher.) 


Chronic  hydrocele  may  begin  in  the  acute  form,  the  effusion  failing 
to  be  absorbed,  and  gradually  increasing  in  quantity,  or  the  onset  may 
be  insidious,  the  patient  first  detecting  the  condition  by  the  increase 
in  the  size  of  the  scrotum. 

Jacobson  holds  that  "  in  the  great  majority  of  cases  the  effusion 
of  fluid  commences  passively,  and  without  any  irritation  or  inflamma- 
tion to  begin  with,  the  causes  predisposing  to  its  production  being 
the  pendent  position,  the  less  vigorous  condition  of  the  cremaster 


682  GENITO-UKINARY   DISEASES   AND  SYPHILIS. 

and  dartos,  feebler  cardiac  circulation,  deficiency  of  tone  in  the 
scrotal  blood-vessels  and  lymphatics,  together  with,  perhaps,  a  ten- 
dency to  venous  congestion  from  hepatic  and  renal  degeneration.  All 
these  conditions,  which  combine  to  bring  about  a  passive  effusion, 
are  naturally  most  active  in  middle  life,  this  being  the  age  when  the 
ordinary  hydrocele  of  the  tunica  vaginalis  is  most  frequently  met  with. 
After  a  while,  as  the  fluid  increases  in  bulk,  it  becomes,  from  ex- 
posure to  friction,  etc.,  liable  to  irritation  and  inflammatory  changes, 
which  show  themselves  both  in  the  fluid  and  sometimes  in  the.tunica 
vaginalis  itself," 

It  is  evident  that  from  the  etiological  stand-point  hydroceles  may 
be  classed  as  those  developing  primarily,  and  those  secondary  to  trau- 

FiG.  206. 


Hydrocele. 

matism,  inflammation,  or  degeneration  of  the  testicle,  epididymis,  or 
cord. 

The  fluid  of  chronic  hydrocele  is  clear,  yellowish,  and  much  like 
that  found  in  ascites.  The  specific  gravity  is  about  1022,  the  reaction 
is  neutral  or  slightly  alkaline,  and  the  fluid  contains  fibrin,  albumen, 
and  paraglobulin.  The  cjuantity  of  albumen  (from  four  to  six  per 
cent.)  found  in  the  fluid  strongly  suggests  the  inflammatory  origin  of 
the  affection. 

In  some  cases  cholesterin  crystals  are  seen  in  the  contents  of  a 
hydrocete,  giving  it  a  beautiful    shimmering   appearance.     There  is 


CHRONIC    HYDROCELE.  683 

sometimes  slight  admixture  of  blood,  the  coloring-matter  of  which 
may  be  deposited  in  the  form  of  blackish  sediment.  Tubercle  bacilli 
have  been  found. 

The  average  amount  of  fluid  is  from  four  to  eight  ounces.  This 
produces  a  tumor  of  such  dimensions  that  it  becomes  inconvenient, 
and  the  patient  seeks  surgical  help.  Some  extraordinarily  large 
accumulations  have  been  observed,  in  one  case  more  than  six 
gallons. 

Kocher  in  309  cases  of  hydrocele  found  that  57  developed  in 
the  first  twenty  years  of  life,  and  76  after  the  fiftieth  year;  the 
remaining  176  were  observed  between  the  twentieth  and  the  fiftieth 
year. 

Kronlein  states  that  thirty-nine  per  cent,  of  hydroceles  are  devel- 
oped in  the  first  year  of  life,  and  forty-eight  and  eight-tenths  per  cent, 
in  the  first  five  years. 

Coley  and  Satterwhite  note  that  of  2214  cases  of  hydrocele,  1603 
were  in  children  less  than  fourteen  years  old.  One  hundred  and  three 
were  in  the  canal  of  Nuck. 

Symptoms. — Chronic  hydrocele,  unlike  the  acute  affection,  is  charac- 
terized by  the  absence  of  symptoms,  the  patient  experiencing  no  incon- 
venience aside  from  the  weight  and  size  of  the  tumor.  The  rate  of 
the  growth  varies  greatly.  It  may  reach  a  large  size  in  a  few  weeks, 
or  may  increase  so  slowly  that  a  tumor  of  troublesome  dimensions  is 
not  formed  for  years. 

The  tumor  is  usually  smooth,  tense,  fluctuating,  and  pyriform, 
with  the  base  below\  It  begins  at  the  lower  portion  of  the  scrotum; 
and  grows  upward.  The  veins  of  the  scrotum  and  cord  are  not 
dilated  in  proportion  to  the  size  of  the  growth.  The  cord  can  usually 
be  felt  at  the  apex  of  the  tumor ;  testicular  pain,  when  elicited,  gives 
information  not  only  as  to  the  condition  of  this  organ  but  also  as  to 
its  position.  The  skin  is  smooth,  white,  and  apparently  normal.  If 
the  tumor  is  held  in  one  hand  and  lightly  percussed  wath  one  finger 
of  the  other,  a  vibjrating  thrill  is  felt  which  is  characteristic  of  fluctu- 
ation. When  the  swelling  reaches  large  dimensions  the  penis  is 
practically  concealed  in  a  fold  of  the  skin.  The  tumor  is  dull  on 
percussion,  is  heavy,  and  when  pushed  back  between  the  legs  springs 
forward  again  to  its  original  position. 

Coincidently  with  the  accumulation  of  fluid  there  is  often  chronic 
thickening  of  the  vaginal  tunic  ;  this  exceptionally  undergoes  cartilagi- 
nous or  calcareous  degeneration.  Sometimes  the  visceral  and  parietal 
walls  of  the  tunica  vaginalis  become  adherent  at  points.  Under  tliese 
circumstances  palpation  may  show  certain  indurated  spots  or  distinct 


684 


GENITO-UKINARY  DISEASES   AND  SYPHILIS. 


Fig.  207. 


Vertical  section  of  a  hydrocele, 
showing  the  testicle  lying  below 
the  cyst.    (Kocher.) 


lobules.  It  is  important  to  know  the  position  of  the  testicle  in  hydro- 
cele, since  otherwise  it  may  be  wounded  in  operations  designed  for 
cure.     This  gland   usually  lies  in  the   mid-posterior  portion  of  the 

tumor.  Exceptionally,  when  there  is  in- 
version or  when  adhesions  have  formed, 
the  testicle  hes  directly  in  front  of  the  tumor 
and  may  be  readily  wounded,  or  it  may 
lie  at  its  lower  pole.  (Fig.  207.)  The  po- 
sition of  the  testicle  is  determined  by  press- 
ure. This,  if  suddenly  exerted  by  one  or 
two  fingers  over  various  parts  of  the  tumor, 
will  produce  the  characteristic  sickening 
pain  when  the  testicle  is  reached.  Trans- 
mitted light  will  better  show  the  position  of 
the  testicle. 

Diagnosis. — The  diagnosis  is  based  upon 
the  development  of  a  tumor  in  the  lower 
part  of  the  scrotum,  its  fluctuation,  its  pyri- 
form  shape,  its  projection  forward,  its  trans- 
lucency,  and  the  small  size  of  the  cord. 
The  light  test  should  be  conducted  in  a  dark 
room,  and  the  skin  of  the  scrotum  and  the  vaginal  tunic  should  be 
made  tense  by  grasping  the  tumor  from  behind  with  the  left  hand. 
The  electric  light  may  be  used  as  described  under  acute  hydrocele,  or 
translucency  can  be  elicited  by  means  of  an  ordinary  candle.  The 
surgeon,  having  placed  the  patient  on  his  back,  makes  the  tumor  tense 
with  the  left  hand,  placing  his  right  hand  on  the  upper  convex  border, 
thus  shading  his  eyes  from  the  source  of  light,  which  is  held  close  to 
the  scrotum  on  the  side  opposite  that  from  which  the  surgeon  is  con- 
ducting his  inspection.  This  test  will  fail  when  the  hydrocele  contains 
a  large  quantity  of  cholesterin  or  when  the  fluid  is  turbid  from  blood, 
fat,  or  spermatozoa.  Omental  hernia  may  be  slightly  translucent,  but 
the  bright  red  glow  so  characteristic  of  ordinary  hydrocele  is  never 
seen.  The  final  diagnosis  is  dependent  upon  aspiration.  This  should 
not  be  practised  until  every  effort  has  been  made  to  exclude  the 
presence  of  hernia.  When  fluctuation,  transparency,  and  testicular 
sensation  cannot  be  elicited,  the  diagnosis  will  depend  upon  the  use 
of  an  aspirating  needle,  or,  better  than  this,  an  incision,  since  thus 
can  be  made  a  thorough  examination  of  both  the  testicle  and  the 
epididymis. 

The  differential  diagnosis  is  to  be  made  from  hernias,  neoplasms, 
other  varieties  of  hydrocele,  and  haematocele. 


CHEONIC   HYDROCELE. 


685 


The  diagnosis  from  hernia,  unless  there  exists  strangulation,  with 
excessive  exudation  and  without  the  typical  abdominal  symptoms,  is 
usually  not  difficult.  In  hernia  there  are  impulse  upon  coughing  and 
percussion  resonance  ;  the  tumor  hangs  directly  down  instead  of  pro- 
truding forward,  grows  smaller  or  disappears  in  the  night,  is  reduced 
with  a  "  flop,"  and  in  its  development  is  first  perceptible  in  the  groin, 
then  slowly  reaches  the  scrotum.  In  none  of  these  respects  does  it 
resemble  hydrocele.  In  the  ordinary  hydrocele  palpation  shows  that 
the  inguinal  canal  is  empty,  fluctuation  is  readily  elicited,  and  trans- 
lucency  is  marked.  These  are  all  characteristics  not 
found  in  hernia.  When,  however,  a  hydrocele  be- 
comes acutely  inflamed  from  injury  or  other  cause, 
and  when  the  history  of  its  formation  is  uncertain, 
diagnosis  may  be  extremely  difficult,  and  must  be 
based  mainly  upon  the  absence  of  abdominal  symp- 
toms. Hernia  and  hydrocele  may  coexist ;  in  this 
case  the  typical  symptoms  of  each  pathological  con- 
dition may  be  elicited.     (Fig.  208.) 

From  hsematocele  the  more  rapid  growth  of  the 
swelling,  the  history  of  an  injury  or  recent  tapping, 
and  the  absence  of  thrill  and  translucency,  will  some- 
times aid  in  the  diagnosis,  but  when  the  tunic  of  the 
hydrocele  is  thickened  or  when  its  contents  are  opaque  diagnosis  is 
impossible. 

These  same  conditions  render  the  diagnosis  from  tumor  difficult. 
Tumor,  however,  is  heavier  and  denser  than  hydrocele,  exhibits 
marked  dilatation  of  the  vessels  of  the  cord  and  scrotum,  and  is 
attended  by  lymphatic  enlargement  (lumbar  and  sacral  glands).  In 
case  of  doubt,  incision  is  indicated. 

Prognosis. — Spontaneous  cure  is  comparatively  common  in  chil- 
dren. It  hardly  ever  takes  place  in  adults.  So  far  as  Ufe  is  con- 
cerned, hydrocele  is  not  dangerous,  though  it  encourages  the  de- 
velopment of  hernia,  may  lead  to  testicular  atrophy,  and  occasionally 
suppurates.  As  a  result  of  traumatism  it  may  rupture  into  the  tissues 
of  the  scrotum. 

Treatment. — The  hydrocele  of  infants  usually  seems  to  be  cured 
by  the  application  of  slightly  stimulating  lotions,  such  as  ammonium 
muriate  ten  grains  to  the  ounce  of  water,  or  an  aqueous  solution  of 
ichthyol  three  per  cent.  The  efficiency  of  these  applications  is  ques- 
tionable, and  it  is  probable  that  when  the  effusion  disappears  this 
occurs  spontaneously,  practically  uninfluenced  by  the  local  treatment. 

The  operative  treatment  may  be  palliative  or  radical. 


Inguinal  hernia  with 
hydrocele.   (Kocher.) 


G86 


GENITO-URINAEY    DISEASES   AND   SYPHILIS. 


Fig.  209. 


Palliative  treatment  consists  in  evacuation  of  the  fluid  contents  of 

the  hydrocele.  In  the  chronic  form  of  the  disease  there  is  always 
reaccumulation,  but  this  tapping  "may  be  repeated  from  time  to  time 
as  the  necessity  for  it  is  indicated  by  full  distention. 

The  position  of  the  testicle  is  first  determined  by  means  of  the 
light  test  and  by  palpation ;  it  is  usually  found  behind  the  sac  and 
somewhat  below  its  middle  third.  The  pres- 
ence of  hernia  must  be  carefully  excluded. 
Exceptionally  the  gut  becomes  invaginated  into 
the  sac  of  a  hydrocele,  and  might  then  readily 
be  wounded  by  the  trocar.  (Fig.  209.J  The 
patient  lies  either  flat  on  his  back  or  in  a  semi- 
recumbent  position.  The  skin  of  the  scrotum 
having  been  thoroughly  disinfected,  the  sac  is 
made  tense  by  seizing  it  from  behind  with  the 
left  hand.  The  trocar  is  plunged  into  the  ante- 
rior part  in  an  upward  and  backward  direc- 
tion, care  being  taken  to  avoid  any  superficial 
vein  which  may  be  apparent ;  the  depth  to 
whch  the  trocar  is  plunged  should  be  limited  by  keeping  the  thumb- 
or  finger-nail  in  contact  with  the  canula  at  one  and  a  half  or  two 
inches  from  the  point  of  the  instrument.  (Fig.  210.)  By  observing 
this  precaution  and  by  thrusting  the  trocar  in  the  proper  direction 
all  danger  of  wounding  the  testicle  is  avoided,  especially  if  its  position 

Fig.  210. 


Inguinal  hernia  inTagi- 
nat±ng  the  upper  portion  of 
the  sac  of  a  hydrocele. 
(Kocher.) 


Tapping  a  hydrocele. 


has  been  before  determined.  When  the  sac  has  been  emptied,  the 
canula  is  immediately  withdrawn  and  the  small  opening  is  closed  by 
a  fragment  of  gauze  held  in  place  by  iodoform  collodion.  In  per- 
forming this  operation  it  is  important  to  have  the  trocar  sharp  and  the 


CHKONIC   HYDKOCELE.  687 

canula  accurately  fitted  to  it,  as  otherwise  the  sac  will  be  pushed 
before  the  point  of  the  instrument  and  will  not  be  opened.  Prac- 
tically the  only  complication  which  can  occur,  save  septic  infection,  is 
wounding  of  either  the  testicle  or  a  large  vein,  with  the  effusion  of 
blood  into  the  hydrocele  sac  or  the  cellular  substance  of  the  scrotum. 
Elevation  and  pressure  applied  by  the  crossed  of  the  perineum  are 
usually  sufficient  to  check  this- bleeding. 

The  radical  treatment  of  hydrocele  is  carried  out  by  the  cutting 
operation. 

Excision. — Excision  of  the  parietal  layer  of  the  tunica  vaginalis  is 
performed  by  dissecting  this  tunic  from  the  tissues  of  the  scrotum  and 
cutting  it  away,  leaving  only  sufficient  to  serve  as  a  normal  covering 
for  the  testicle,  or  even  less  than  this. 

The  field  of  operation  is  prepared  in  accordance  with  general  sur- 
gical principles.  The  sac  is  made  tense  by  an  assistant,  and  the  scro- 
tal covering  is  divided  by  a  vertical  cut  running  from  the  top  to  the 
bottom  of  the  tumor.  After  complete  hsemostasis  the  vaginal  tunic  is 
incised  sufficiently  to  admit  a  finger,  and  the  condition  and  position 
of  the  testicle  are  clearly  defined.  The  remainder  of  the  sac  is  then 
split  up  with  a  blunt  pair  of  scissors,  and  the  tunica  vaginalis  is  dis- 
sected from  the  scrotum.  This  can  usually  be  accomplished  by  rough 
sponging,  and  tearing  with  the  fingers,  or  by  the  use  of  the  blunt  dis- 
sector. The  bleeding  points  should  be  picked  up  with  haemostatic 
forceps,  which  should  be  left  on  until  the  operation  is  completed. 
When  the  parietal  layer  has  been  dissected  free  it  should  be  cut  away 
from  the  testicle  and  epididymis  as  closely  as  possible.  Cysts  or 
fibrous  bodies  attached  to  the  visceral  portion  of  the  sac  should  be 
removed.     The  wound  should  be  closed  without  drainage. 

This  operation  may  be  variously  modified.  Enough  of  the  vaginal 
tunic  may  be  left  to  cover  the  testicle ;  the  edges  of  the  vaginal  tunic 
may  be  sutured  to  the  borders  of  the  skin  wound  and  gauze  drainage 
may  be  employed ;  or  the  vaginal  tunic  may  be  inverted  by  a  couple 
of  sutures,  folding  it  behind  the  epididymis,  the  skin  wound  being 
closed  without  drainage. 

The  external  dressing  should  be  antiseptic  and  compressing 
(crossed  of  the  perineum),  and  great  care  should  be-  taken  .to  prevent 
infection  from  §oihng  of  the  dressing  with  urine  or  faeces.  Sutures  are 
removed  on  the  third  to  the  fifth  day.  ,  Packing  is  replaced  at  this 
time,  but  very  little  gauze  is  used.  Drainage  is  dispensed  with  alto- 
gether in  from  seven  to  ten  days.  The  main  complication  of  this 
operation  is  suppuration,  which  is  avoidable.  It  is  indicated  when 
incision  and  drainage  fail,  and  primarily  when  the  walls  of  the  sac 
are  thick  and  degenerated. 


688 


GENITO-TJEIXAET   DISEASES    AXD   SYPHILIS. 


Zancarol  has  operated  upon  fifty-eight  patients  without  a  single 
failure  by  making  a  long  incision,  excising  a  large  portion  of  the  vagi- 
nal tunic  and  suturing  without  drainage.  Augagneur  reports  sixty 
completely  successful  cases. 

Exceptionally  the  scrotal  hydrocele  is  bilocular. — that  is,  there  are 
two  distinct  cavities  filled  with  fluid  and  communicating  with  each 
other  by  a  comparatively  narrow  opening.  One  variety  of  this  bilocu- 
lar formation  is  described  by  Curiing.  It  is  due  to  the  distention  of 
the  visceral  portion  of  the  vaginal  tunic  passing  between  the  body  of 

Fig.  211. 


Bilocular  hydrocele.  rBi^raud.1  iT,  testicle  ;  X/i,  epididymis ;  S,  vas;  r.y,  cavity  of  the  tunica 
vaginalis  ;  D,  cavity  of  the  diverticulum  ;  T.c,  tunica  vaginalis  communis  ;  Z,  cellular  tissue  betsveen 
the  tunica  propria  and  the  tunica  communis.    (Kocher.) 

the  testis  and  the  epididymis.  Normally,  in  this  position  there  is  a 
pouch.  Avhich.  under  tension,  may  extend,  forming  a  tumor,  to  the 
inner  side  of  the  testis :  the  opening  into  this  accumulation  is  from 
the  outer  side.  Beraud  has  described  two  cases  of  diverticular  devel- 
opment (Fig.  211)  due  to  the  lessened  resistance  of  a  certain  portion 
of  the  parietal  vaginal  tunic,  which,  yielding  to  the  pressure  of  effu- 
sion, forms  a  distinct  pouch. 

There  is  a  perineal  form  of  bilocular  hydrocele  dependent  upon 
trauma,  causing  rupture  of  a  pre-existing  hydrocele  and  an  effusion 
of  the  contents  into  the  perineum.  This  effusion  becomes  encapsu- 
lated. These  bilocular  hydroceles  are  usually  translucent,  but  may 
reveal  on  examination  two  distinct  sacs,  which  may  be  shown  by 
alternate  pressure  to  communicate  with  each  other. 


CHKOjSTIC    HYDEOCELB. 


689 


Multilocular  hydrocele  of  the  testicle  may  be  hereditary  or  may  be 
due  to  inflammatory  adhesions,  which  by  causing  agglutination  be- 
tween the  folds  of  the  vaginal  tunic,  but  without  obliterating  it,  leave 
a  number  of  cavities  into  which  serum  can  be  exuded.  On  palpation 
the  tumor  will  be  found  somewhat  irregular  in  outline,  and  aspiration 
will  evacuate  only  a  small  portion  of  its  contents,  not  materially  dimin- 
ishing the  tension  of  the  rest  of  the  tumor. 

Congenital  Hydrocele. — This  form  of  hydrocele  depends  for 
its  existence  upon  the  maintenance  of  a  communication  between  the 
tunica  vaginalis  and  the  abdominal  cavity.  The  funicular  portion  of 
the  tunic  does  not  become  obliterated.  The  fluid  may  come  from  the 
general  abdominal  cavity  or  may  be  exuded  from  the  vaginal  tunic. 
It  may  develop  in  early  infancy  or  not  until  later  life. 

Symptoms. — When  the  vaginal  tunic  forms  a  pouch  which  opens 
into  the  general  peritoneal  cavity  and  there  is  serous  efl'usion  into  this 
pouch,  there  will  be  the  customary  symptoms  of  hydrocele,  obscured 
only  by  the  facts  that  on  recumbency  the  tumor  disappears,  to  reap- 
pear when  the  patient  assumes  the  erect  position,  that  there  is  distinct 
impulse  on  coughing,  and  that  by  bimanual  pressure  the  tumor  can  be 
partially  reduced  into  the  abdominal  cavity.  After  the  tumor  has  dis- 
appeared on  recumbency,  even  though  gentle  pressure  be  maintained 
on  the  external  ring  there  will  be  reaccumulation  on  rising.  This  form 
of  hydrocele  is  occasionally  complicated  by  congenital  hernia  (Fig.  212), 
though  the  opening  into  the  abdominal  cavity  is  usually  too  small  to 

allow  the  intestine  or  omentum  to  pass 
through  it. 

This  form  of  hydrocele  is  compara- 
tively rare.  Though  we  have  frequently 
seen  children  exhibiting  a  hydrocele 
which  their  mothers  stated  grew  much 
smaller  during  the  night,  we  have  ob- 
served very  few  cases  in  which  the 
tumor  could  be  made  to  disappear  dur- 
ing an  examination. 

Diagnosis. — Hydrocele  in  children  is 
so  extensively  translucent  that  this  char- 
acteristic of  the  growth  can  often  be  per- 
ceived by  daylight  through  the  thin  tis- 
sues of  the-  scrotum.  The  only  affection 
with  which  congenital  hydrocele  is  likely  to  be  confounded  is  hernia. 
Both  tumors  give  impulse  on  coughing,  and  are  reducible.  The  hernia, 
however,  is  often  resonant  on  percussion,  goes  back  suddenly  with  a 


Fig.  212. 


Congenital  hydrocele  with  hernia. 


690  GENITO-UEIISrAEY   DISEASES   AND   SYPHILIS. 

distinct  "  flop,"  and  will  not  return  if  light  pressure  is  maintained  over 
the  external  ring ;  or,  should  it  overcome  this  pressure,  the  omentum 
or  gut  will  be  felt  to  slide  beneath  the  finger.  The  hydrocele  is  dull 
on  percussion,  is  reduced  rather  gradually  without  a  distinct  "  flop," 
and  returns  when  the  patient  is  in  the  erect  position,  even  though  light 
pressure  be  maintained  over  the  external  ring,  the  swelling  forming 
gradually  at  the  bottom  of  the  scrotum,  and  without  the  sensation  of 
a  body  sliding  beneath  the  finger. 

Prognosis. — This  is  good,  as  these  hydroceles  commonly  disappear 
spontaneously  with  obliteration  of  the  funicular  portion  of  the  vaginal 
tunic. 

Treatment. — The  obliteration  of  the  vaginal  tunic  is  favored  by 
the  application  of  a  truss,  which  maybe  required  for  the  treatment 
of  the  coexistent  hernia.  In  case  the  truss  is  not  successful  the  fluid 
should  be  aspirated.  Should  it  reaccumulate,  permanent  drainage 
is  secured  by  means  of  a  small  drainage-tube  passed  through  and 
through  the  sac.  The  scrotum  is  then  enveloped  in  sterile  gauze 
generously  applied,  and  protected  from  contamination  with  urine  and 
feces  by  an  outer  investment  of  rubber  or  oiled  silk.  This  dressing 
should  be  frequently  changed.  Since  the  tunica  vaginalis  communicates 
directly  with  the  peritoneal  cavity,  the  importance  of  absolute  clean- 
liness in  operating  on  congenital  hydrocele  is  evident.  We  have 
known  of  one  death  from  peritonitis  following  the  careless  application 
of  a  seton. 

The  best  operation,  and  one  which  should  be  followed,  as  a  rule, 
when  the  consent  of  the  parents  can  be  obtained,  is  that  of  antiseptic 
incision  with  the  performance  of  a  radical  operation  for  the  cure  of 
any  hernia  that  may  be  present,  and  closure  of  the  abdominal  ring  in 
any  case.  The  patient  is  prepared  as  for  the  operation  for  hernia, 
and  an  incision  similar  to  that  for  a  radical  cure  is  made.  The 
funiculo-vaginal  process,  being  identified,  is  carefully  separated  from 
the  surrounding  tissues  and  from  the  cord,  divided  a  short  distance 
above  the  testis,  and  converted  into  a  tunica  vaginalis.  The  remain- 
ing portion  separated  from  the  surrounding  structures  is  treated 
as  the  sac  of  a  hernia,  and  radical  cure  is  performed  by  Bassini's 
method. 

Infantile  Hydrocele. — This  is  an  effusion  into  a  sac  formed  by 
more  or  less  of  the  unobliterated  funicular  portion  of  the  vaginal 
tunic.  This  sac  is  closed  from  the  peritoneal  cavity  above,  and  com- 
municates with  the  tunica  vaginalis  testis  below. 

Symptoms. — The  symptoms  are  those  of  hydrocele  extending  well 


CHRONIC    HYDROCELE.  ggi 

up  along  the  cord.    The  tumor  shows  no  change  in  tension  on  recum- 
bency. 

Treatment. — Simple  evacuation  with  the  finest  needle  of  the  aspi- 
rator may  be  followed  by  cur 3,  since  there  is  a  natural  tendency, 
towards  obliteration  of  the  sac  on  evacuation  of  its  contents. 

Should  this  be  unsuccessful,  the  use  of  carbolic  acid  injections  may 
be  tried.  The  fluid  should  be  drawn  off  with  a  large  hypodermic 
needle,  and  from  one  to  three  minims  of  carbolic  acid  injected ;  this 
should  be  gently  diffused  through  the  sac. 

The  insertion  of  a  small  drainage-tube,  indeed,  any  of  the  well- 
recognized  forms  of  treatment,  will  give  satisfactory  results. 

Jacobson  advises,  as  a  rule,  acupuncture.  The  swelling  is  made 
tense,  and  half  a  dozen  punctures  are  made  into  the  front  and  lower 
surfaces  with  an  ordinary  surgical  needle,  which  should  be  slightly 
rotated  before  it  is  withdrawn.  Jets  of  fluid  follow  each  puncture ; 
there  is  a  good  deal  of  oozing,  as  well  as  some  escape  of  fluid  into  the 
cellular  tissues  of  the  scrotum.  Dilute  lead  water  is  subsequently 
applied,  and  the  parts  are  supported. 

BiLOCuLAR  Hydrocele. — This  is  a  comparatively  rare  form  of  in- 
fantile hydrocele.  The  funicular  portion  of  the  tunica  vaginalis  is 
commonly  obhte rated  at  the  internal  ring.  Below  this  the  whole 
tunica  vaginalis  may  be  patulous,  or  it  may  be  closed  just  above  the 
position  of  the  testis.  As  the  fluid  accumulates,  sacculation  develops, 
the  tumor  extending  either  backward  and  downward  into  the  pelvis, 
or  more  commonly  upward  and  inward  between  the  abdominal 
muscles  and  the  peritoneum. 

Symptoms. — In  addition  to  the  ordinary  symptoms  of  hydrocele — 
i.e.,  fluctuation,  dulness  on  percussion,  translucency,  and  smooth  sur- 
face— there  will  be  found  a  constriction  separating  the  tumor  into  two 
portions.  Alternate  pressure  will  show  that  the  fluid  in  these  portions 
intercommunicates,  and  exceptionally,  when  tension  is  not  great,  the 
opening  of  communication  may  be  distinctly  felt.  It  is  usually  placed 
at  the  external  ring.  The  scrotal  tumor  is  smaller  than  that  formed 
in  the  abdominal  parietes.  There  is  distinct,  impulse  on  coughing. 
The  forms  of  bilocular  hydrocele  of  the  tunica  vaginalis  testis  have 
been  described.  , 

Treatment. — Bilocular  hydrocele  is  best  treated  by  incision,  with 
removal  of  the  scir",  or  as  much  of  it  as  is  accessible.  Care  should 
be  taken  to  avoid  opening  the  general  peritoneal  cavity. 

Inguinal  Hydrocele. — The  hydrocele  which  forms  in  the  vagi- 
nal tunic  of  the  undescended  testicle  may  be  of  the  ordinary  variety 
or  may  be  congenital,  communication  persisting  between  the  vaginal 
tunic  and  the  general  peritoneal  cavity.     We  have  seen  it  distinctly 


(392  GENITO-UEIXAKY   DISEASES   AXD   SYPHILIS. 

bilocular,  one  pouch  passing  upward  for  three  inches  between  the 
peritoneum  and  the  transversalis  fascia,  the  second  pouch  extending 
through  the  external  ring  and  forming  a  tumor  in  the  scrotum. 

Symptoms. — The  symptoms  are  those  already  given  as  character- 
istic of  hydrocele,  except  that  the  tumor  is  formed  in  the  inguinal 
region. 

Treatment. — Since  it  is  very  difficult  to  exclude  the  presence  of 
hernia,  inguinal  hydrocele  should  be  treated  by  open  incision,  the 
sac  being  partly  or  completely  removed  and  drainage  established. 
When  the  testis  is  wasted  the  appropriate  operation  is  castration. 

Fatty  Hydrocele. — This  has  been  variously  described  as  chylous 
or  milky  hydrocele,  and  is  the  name  given  to  a  collection  of  fluid 
resembhng  milk  or  chyle  in  the  tunica  vaginalis  testis.  It  may  be 
produced  by  lymphorrhagia  following  an  actual  rupture  of  the  lym- 
phatic channels  or  by  leakage  of  lymph  through  the  walls  of  the 
vessels.  This  latter  method  is  the  more  common,  and  is  dependent 
upon  obstruction  to  the  return  of  the  lymph,  either  by  an  inflamma- 
tory process  or  by  the  presence  of  filariae. 

It  has  been  maintained  that  the  presence  of  fat  is  due  to  degen- 
erative changes  occurring  in  a  simple  hydrocele.  "Whatever  the  cau- 
sation, the  density  of  the  contained  fluid  renders  diagnosis  difficult, 
since  translucency  is  lacking.  The  other  symptoms  of  hydrocele  are 
present.  If  the  effusion  is  double  and  the  patient  is  an  inhabitant  of 
a  tropical  chmate,  an  examination  for  filariae  should  be  made. 

Treatment. — Excision  of  the  sac  is  indicated. 

HYDROCELE    OF   THE    CORD. 

Acute  Hydrocele  of  the  Cord. — This  is  a  rare  condition,  seen 
most  frequently  in  young  subjects  after  strain.  A  translucent  swelling 
forms,  containing  fluid  resembling  that  of  ordinary  hydrocele.  The 
effusion  is  limited  by  the  investment  of  the  cord,  and  is  rather  an  acute 
cedema  into  loose  cellular  tissue  than  an  effusion  of  fluid  into  a  sac. 

Molliere  holds  that  this  acute  oedema  is  due  to  rheumatismal  funic- 
ulitis.  The  affection  develops  with  local  inflammatory  phenomena, 
but  without  much  pain. 

It  may  simulate  an  incarcerated  hernia,  but  may  be  distinguished 
by  its  translucency,  and  by  dulness  on  percussion  and  absence  of 
abdominal  symptoms.  The  sweUing  may  involve  the  entire  cord, 
transforming  it  into  a  soft  sausage-shaped  mass. 

Treatment. — Compresses  wet  in  dilute  lead  water  and  alcohol  and 
held  in  place  by  a  crossed  of  the  perineum  gauze  bandage  will  limit 
.the  swelling. 


HYDROCELE    OF   THE    CORD. 


693 


Diffuse  Hydrocele  of  the  Cord. — This  is  a  general  infiltration 
into  the  cellular  tissue  enclosed  by  the  fascia  which  invests  the  cord. 
The  tunica  vaginalis  is  not  affected ;  indeed,  the  funicular  portion  of 
this  tunic  is  usually  completely  obliterated.  The  etiology  is  obscure, 
but  is  probably  dependent  on  passive  exudation  from  the  veins  and 
lymphatics  of  the  cord  due  to  pressure  interference  with  return  cir- 
culation. It  is  not  associated  with  general  oedema  of  the  penis  and 
scrotum,  since  the  fibrous  tunic  of  the  cord  entirely  separates  this 
structure  from  the  cellular  tissue  lying  beneath  the  deep  layer  of  the 
superficial  fascia. 

Symptoms. — The  tumor  forms  gradually,  with  very  few  symptoms. 
It  may  involve  the  entire  length  of  the  cord,  reaching  from  the  tes- 
ticle to  the  internal  ring  and  filling  the  inguinal  canal.  It  is  broader 
in  its  lower  portion,  and  may  cover  the  upper  portion  of  the  testis  and 
epididymis  as  a  cap.  On  placing  the  patient  on  his  back  and  ele- 
vating the  testicle  the  swelling  gradually  diminishes,  but  does  not  dis- 
appear entirely.  On  gentle  continued  pressure  deep  pitting  may  be 
detected.  The  infiltration  is  painless  unless  it  be  a  sequel  of  acute 
inflammation,  is  doughy  rather  than  fluctuating,  and  gives  the  test  of 
translucency. 

The  differential  diagnosis  must  be  made  from  omental  hernia. 
This  gives  a  more  distinct  impulse  on  coughing,  is  not  so  smooth,  can 

be  reduced  suddenly  and  completely,  and 
is  very  feebly  translucent.  In  irreducible 
omental  hernias  of  fat  people  a  pre-opera- 
tive  diagnosis  may  be  impossible. 

Treatment. — When  the  infiltration  pro- 
duces a  tumor  of  such  size  as  to  cause  in- 
convenience from  its .  bulk,  incision  and 
drainage  are  indicated. 

Encysted  hydrocele  of  the  cord,  or 
funicular  hydrocele,  consists  of  an  accumu- 
mulation  of  fluid  within  an  unobliterated 
portion  of  the  funicular  portion  of  the  tunica 
vaginalis.  This  accumulation  is  closed  from 
the  peritoneal  cavity  above  and  from  the 
tunica  vaginalis  testis  below.  The  hydro- 
cele may  be  unilocular,  bilocular,  or  multilocular,  in  the  latter  case 
forming  a  series  of  small  cysts  along  the  course  of  the  cord.  These 
cysts  may  be  placed  in  the  inguinal  canal,  and  are  more  common  on 
the  right  side.  They  are  usually  observed  in  children,  and  may  be 
complicated  by  hernia.     (Fig.  213.) 


Inguinal  hernia,  with  hydrocele  of 
the  cord.    (Kocher.) 


694  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

Symptoms. — A  smooth,  dense,  ovoid,  fluctuating  swelling  is  formed 
in  some  portion  of  the  spermatic  cord.  By  transmitted  light  the 
tumor  is  found  to  be  translucent,  and  the  testicle  can  usually  be 
recognized  below  it. 

Diagnosis. — This  is  based  on  the  position  of  the  cyst  or  cysts. 
Encysted  hydrocele  of  the  testicle,  though  sometimes  extending  up- 
ward along  the  cord,  is  attached  to  the  testis  and  the  epididymis. 
In  hydrocele  of  the  cord  palpation  will  show  that  the  tumor  is  not 
directly  connected  ^\T[th  the  testicle.  Hydrocele  of  the  cord  is  dis- 
tinguished from  hernia  by  absence  of  impulse  on  coughing,  inability 
to  reduce  the  tumor  entirely  within  the  abdominal  cavity,  though  it  is 
often  easily  pressed  back  into  the  inguinal  canal,  and  absence  of  tym- 
pany and  gurgling.     The  hernia  is  not  translucent. 

Treatment. — In  children  spontaneous  cure  may  occur.  Incision 
followed  by  drainage  is  probably  the  safest  method  of  treatment,  and 
the  one  most  certain  to  effect  cure.  Multiple  puncture  is  also  efficient. 
In  elderly  people,  where  radical  measures  are  not  desired,  repeated 
tappings  will  be  necessary  to  afford  rehef. 

Hydrocele  into  a  Hernial  Sac. — An  effusion  of  serum  which 
may  closely  simulate  hydrocele  may  take  place  into  the  sac  of  an  in- 
guinal or  a  scrotal  hernia.  This  sac  may  have  become  obliterated  from 
the  general  peritoneal  cavity  and  contain  only  fluid,  or  it  may  contain 
in  addition  to  the  fluid  a  portion  of  gut  or  omentum,  the  hernia  being 
incarcerated.  There  is  always  more  or  less  effusion  in  combination 
with  incarcerated  hernia,  and  the  sac  not  infrequently  becomes  thick- 
ened and  fibrous,  closely  resembhng  the  investment  of  chronic  hydro- 
cele or  a  hgematocele.  The  symptoms  are  those  of  a  hernia  followed 
by  the  development  of  a  fluctuating,  probably  translucent  tumor. 
When  the  sac  contains  both  fluid  and  intestinal  contents,  tender- 
ness and  possibly  resonance  in  the  inguinal  region  may  lead  to 
a  correct  diagnosis.  Frequently  the  diagnosis  is  made  only  after 
incision. 

Treatment. — Excision  of  the  sac  and  an  operation  for  the  radical 
cure  of  the  hernia  constitute  the  only  practical  treatment. 

HEMATOCELE. 

Hgematocele  is  a  collection  of  blood  or  bloody  fluid  in  the  vaginal 
tunic  of  the  testicle  or  cord  or  in  the  substance  of  either  of  these 
structures.  As  is  the  case  with  hydrocele,  the  effusion  may  be  acute 
or  chronic. 

Heematocele  of  the  Tunica  Vaginalis. — This  affection  as  com- 
pared with  hydrocele  is  very  rare.     It  may  develop  in  the  acute  form 


HEMATOCELE.  695 

as  a  result  of  punctured  wound  or  rupture  of  the  testis,  or  may  be 
caused  by  a  blow  or  by  violent  muscular  strain.  Svalin  noted  blood 
effusion  into  the  tunica  vaginaHs  and  the  scrotal  tissues  after  severe 
coughing.  There  may  be  bleeding  into  a  previously  healthy  tunica 
vaginalis ;  commonly  it  is  into  a  previously  inflamed  sac,  and  often 
it  occurs  as  a  complication  of  hydrocele.  It  may  be  complicated  by 
scrotal  haematoma. 

The  development  of  acute  hsematocele  (haematoma)  is  characterized 
by  severe  pain,  which  may  be  sickening  in  character,  and  the  rapid 
formation  of  a  tumor. 

This  tumor  completely  envelops  the  testicle,  and  closely  corre- 
sponds to  it  in  shape. 

The  blood  may  coagulate  or  remain  fluid.  The  tumor  never 
reaches  large  dimensions,  since  it  forms  so  rapidly  that  the  tunica 
vaginaKs  ruptures,  thus  allowing  the  blood  to  escape  into  the  scrotal' 
tissues! 

Symptoms. — The  distention  of  the  vaginal  tunic  is  usually  obscured 
by  the  concomitant  scrotal  bloo'd  effusion.  After  this  has  been  ab- 
sorbed there  may  be  found  a  fluctuating  tumor  impervious  to  light 
and  giving  on  exploratory  puncture  blood  or  blood-stained  fluid. 

Exceptionally  complete  resolution  takes  place.  Usually  the  tunica 
vaginalis  undergoes  the  alterations  characteristic  of  chronic  hydrocele. 

Treatment. — Acute  haematocele  incident  to  trauma  is  treated  by 
rest,  elevation  of  the  parts,  and  the  application  of  evaporating  lotions 
or  the  ice-bag.  If  the  swelling  is  rapid  and  progressive,  clots  should 
be  evacuated  through  an  incision,  followed  by  search  for  the  bleeding 
vessel.  The  scrotal  infiltration  is  quickly  absorbed.  If  on  its  disap- 
pearance the  vaginal  tunic  is  found  distended,  its  contents  should  be 
evacuated  through  a  free  incision,  since  otherwise  the  tunica  vaginahs 
becomes  chronically  inflamed  and  a  chronic  haematocele  may  form. 

Chronic  Hsematocele  of  the  Tunica  Vaginahs. — This  affec- 
tion is  dependent  upon  chronic  inflammation  of  the  tunica  vaginalis, 
and  is  properly  called  peri-orchitis  haemorrhagica  or  haemorrhagic 
vaginalitis.  The  blood  effusion  is  simply  a  symptom  of  such  inflam- 
mation, which,  in  turn,  is  generally  regarded  as  secondary  to  disease 
of  the  epididymis  or  of  the  testis. 

Gosselin  recognizes  three  degrees  of  haematocele,  basing  his  classi- 
fication upon  the  extent  of  lesion  which  the  walls  of  the  sac  show. 
The  first  degree  is  characterized  by  moderate  thickening,  the  vaginal 
tunic  being  but  little  altered  beyond  some  increase  in  vascularity. 
There  is  a  deposit  of  thin,  non-adherent  false  membrane.  On  evacua- 
tion of  its  contents  the  sac  will  collapse.  The  second  degree  is  char- 
acterized by  increased  thickness  of  both  the  vaginal  tunic  and  the 


596  GENITO-URINARY   DISEASES  AND    SYPHILIS. 

false  membranes,  but  the  walls  are  too  rigid  to  collapse  on  evacuation 
of  the  contents  of  the  sac.     The  condition  is  progressive. 

The  third  degree  is  characterized  by  still  greater  thickening  and 
rigidity.  Areas  of  cartilaginous  and  calcareous  transformation  are 
observed.  Barigandin  described  a  case  of  ossification  of  the  tunica 
vaginalis.  In  the  thickened  walls  are  "often  found  foci  of  soft  granula- 
tion-tissue or  interstitial  hemorrhages.  The  false  membrane,  at  first 
deposited  in  a  thin  layer  and  extremely  vascular,  ultimately  has  its 
blood-supply  greatly  diminished  or  entirely  cut  off  by  organization 
and  contraction  of  the  inflammatory  infiltrate,  and  it  is  likely  to  slough. 
In  old  cases  it  is  so  intimately  connected  with  the  tunica  propria  that 
it  is  impossible  to  strip  it  from  the  latter. 

The  thickened  sac  is  made  up  partly  of  fibrinous  deposits  and 
partly  by  organization  of  the  infiltrate  into  the  subserous  connective 
tissue. 

On  incising  a  hsematocele  blood  more  or  less  altered  or  blood 
mingled  with  the  fluid  of  the  hydrocele  is  found.  In  old  cases  the 
blood  is  altered  both  in  color  and  in  consistence.  It  may  form  a 
chocolate-colored  or  black  syrupy,  or  even  a  gelatinous  mass.  When 
the  bleeding  is  into  the  sac  of  a  hydrocele  the  fluid  is  clear  red  and 
contains  clots. 

In  recent  cases — i.e.,  those  in  which  the  sac  is  not  greatly  thick- 
ened— the  testicle  may  not  be  appreciably  altered,  even  though  the 
tumor  is  of  great  size.  As  induration  and  thickening,  in  consequence 
of  subserous  infiltration  and  organization,  take  place,  the  albuginea 
becomes  involved,  together  with  its  fibrous  trabeculse,  and  there  re- 
sults an  atrophy  of  the  tubules  with  fatty  degeneration  of  their  epi- 
thelium. In  the  large,  greatly  thickened,  degenerated  sacs  careful 
search  may  fail  to  discover  even  a  trace  of  the  testis. 

The  testicle  usually  lies  in  the  lower  posterior  portion  of  the 
tumor.  In  the  early  stages  of  development,  before  the  gland  has 
atrophied,  palpation,  eliciting  testicular  sensation,  will  probably  enable 
the  surgeon  to  determine  its  exact  position.  In  the  late  stages  of 
hsematocele  where  the  sac  is  greatly  thickened  it  may  be  impossible  to 
determine  whether  the  testicle  lies  in  front  of  or  behind  the  swelling. 
In  such  a  case  operation  should  be  conducted  with  great  care,  the 
tissues  being  examined  before  they  are  cut. 

Chronic  hsematocele  is  of  slow  formation,  and  is  most  common 
between  the  fortieth  and  the  sixtieth  year  of  age.  It  may  grow 
steadily,  or  may  rapidly  increase  in  size  after  brief  intervals  of  quies- 
cence. The  tumor  is  hard,  painless,  ovoid  or  pyriform  in  shape,  with 
smooth  or  bosselated  surface,  showing  at  times  spots  of  softening 
and  possibly  dense  areas  of  calcareous  degeneration. 


HEMATOCELE.  697 

Diagnosis. — This  is  founded  on  the  smooth  bossed  surface,  the 
rounded  or  oval  shape,  the  tense,  elastic  feel,  the  varying  consistence, 
and  the  absence  in  any  portion  of  the  tumor  of  either  a  projection  or 
a  depression  corresponding  to  the  position  of  the  testicle  or  the  epi- 
didymis. There  is  usually  a  history  of  traumatism,  strain,  or  pre- 
existing hydrocele.  The  general  growth  of  the  tumor  is  slow,  but 
it  exhibits  irregularly  recurring  periods  of  rapid  increase  in  size, 
attended  by  pain,  heat,  and  swelling.  These  sudden  increments  are 
due  to  fresh  hemorrhages  into  the  sac.  The  tumor  is  not  translucent. 
The  final  diagnosis  depends  upon  aspiration.  For  the  purpose  of  thus 
confirming  the  diagnosis  a  needle  longer  than  that  employed  in  the 
ordinary  hypodermic  syringe  is  required,  and  it  mitst  be  remem- 
bered that  the  contents  of  the  sac  will  not  necessarily  be  obviously 
bloody. 

Omental  hernia  may  strongly  resemble  a  chronic  haematocele. 
The  latter,  however,  begins  within  the  scrotum,  gives  no  history  of 
having  been  reducible  at  any  period  of  its  development,  and  usually 
involves  only  the  lower  portion  of  the  cord,  the  inguinal  canal  remain- 
ing free.  Unless  the  haematocele  extends  well  up  into  the  inguinal 
canal  there  will  be  no  impulse  on  coughing. 

The  distinction  from  hydrocele  is  dependent  upon  absence  of  dis- 
tinct thrill  and  fluctuation,  failure  to  detect  translucency,  and  finally 
the  result  of  exploratory  tapping  or  incision.  Diagnosis  from  chronic 
orchitis  or  malignant  growths  may  be  absolutely  impossible,  except 
from  the  history.  In  case  of  doubt  there  should  be  no  hesitation  in 
deciding  the  matter  by  an  aseptic  incision. 

Prognosis. — There  is  no  tendency  towards  spontaneous  cure.  The 
disease  may,  however,  become  self-limited.  It  usually  progresses, 
forming  ultimately  a  large  tumor,  which  inconveniences  mainly  by  its 
bulk  and  by  the  pain  and  disability  dependent  upon  the  intercurrent 
attacks  of  acute  inflammation.  Even  though  the  patient  experiences 
no  mechanical  inconvenience  from  the  growth,  it  inevitably  destroys 
the  secreting  function  of  the  testicle  and  predisposes  to  suppuration 
and  to  malignant  degeneration.  Suppuration  may  follow  the  use  of 
an  apparently  clean  trocar,  since  the  conditions  are  exceedingly  favor- 
able to  germ-growth.  At  times  it  occurs  from  haematogenous  infec- 
tion, the  predisposing  cause  being  trauma.  The  heematocele  and  the 
scrotum  of  the  affected  side  become  oedematous  and  painful,  the  symp- 
toms of  constitutional  infection  develop,  and  softening  takes  place, 
followed  by  grumous  discharge.  Some  cases  of  malignant  degenera- 
tion of  heematocele  have  been  recorded.  It  is  probable,  however, 
that  in  these  the  heematocele  comphcated  cancer  and  developed 
secondarily. 


698  GENITO-URINAKY   DISEASES   AND  SYPHILIS. 

Treatment. — ^Chronic  hsematocele  should  be  treated  by  incision 
and  curetting,  decortication,  or  castration.  Tapping  and  injection  of 
iodine,  and  even  simple  incision,  operations  usually  curative  in  the 
case  of  Ifydrocele,  are  insufficient. 

Incision  followed  by  curetting  is  the  simplest  and  most  easily  per- 
formed of  the  radical  operations,  and  is  successful  when  the  walls  of 
the  sac  have  not  become  extensively  infiltrated  and  rigid.  The  cavity 
of  the  cyst  is  opened  by  a  free  incision,  which,  unless  the  position  of 
the  testicle  has  been  determined  previously,  is  deepened  with  the 
utmost  precaution.  The  contents  of  the  sac  are  washed  out,  and  the 
whole  interior  is  scraped  smooth  with  a  sharp  curette.  So  much  of 
the  outer  wall  of  the  vaginal  tunic  as  can  be  easily  freed  is  cut  away, 
and  the  remaining  portion  is  sewed  to  the  skin.  The  cavity  is  then 
loosely  packed  with  iodoform  gauze,  and  is  allowed  to  heal  by  granu- 
lation. 

When,  because  of  great  thickening  and  rigidity,  with  cartilaginous 
or  calcareous  deposits,  it  is  evidently  impossible  for  the  walls  of  the  sac 
to  come  together  and  become  obliterated,  or  even  to  produce  healthy 
granulations,  decortication  is  indicated.  This  is  practised  by  opening 
the  tunica  vaginalis  and  tearing  and  dissecting  away  from  it  the  thick 
layers  of  false  membrane  by  means  of  the  finger  or  by  rough  sponging ; 
more  often  the  knife  or  scissors  are  required.  When  the  false  mem- 
brane has  been  reflected  as  closely  as  possible  to  the  testis  and  cord 
without  wounding  these  structures,  it  is  cut  away,  the  edges  of  the 
vaginal  tunic  are  sutured  to  the  skin,  and  the  wound  is  hghtly  packed. 

Castration  is  indicated  in  long-standing  hsematoceles  in  old  sub- 
jects when  there  is  reason  to  believe  that  the  testicle  is  partially  or 
completely  atrophied  and  the  patient  is  not  in  a  condition  to  stand  a 
prolonged  operation. 

Encysted  Hsematocele  of  the  Testis. — This  is  an  extravasa- 
tion of  blood  into  an  encysted  hydrocele.  The  symptoms  are  those 
of  sudden  increase  of  a  pre-existing  encysted  hydrocele,  with  inflam- 
matory .phenomena.  The  tumor  fluctuates  at  first,  but  is  not  trans- 
lucent. 

Treatment — Either  total  excision  of  the  sac  or  castration  is  indi- 
cated. 

Intratesticular  Hsematocele  is -due  to  traumatism.  After  an 
injury  persistent  pain  and  swelling  not  dependent  on  hydrocele  might 
suggest  parenchymatous  effusion  of  blood,  though,  except  by  puncture, 
an  early  diagnosis  from  acute  orchitis  would  be  impossible.  The  pain 
of  these  hsematomata  is  said  to  be  extremely  severe  and  persistent. 


HEMATOCELE    OF   THE   COED.  699 

The  detection  of  a  fluctuating  area  in  the  testicle  proper  would  indicate 
incision  and  drainage. 

Parenchymatous  heematocele  of  the  epididymis  is  reported  by 
Jacobson. 

Treatment. — Immediately  following  injury  of  the  testicle,  rest,  ele- 
vation of  the  parts,  and  the  application  of  evaporating  lotions  are  in- 
dicated. Later,  on  the  subsidence  of  acute  inflammatory  phenomena, 
the  pressure  suspensory  bandage  should  be  worn.  If  the  pain  remains 
intense,  the  testicle  showing  a  moderate  increase  in  size  not  dependent 
upon  hydrocele,  exploratory  puncture  of  this  gland  with  the  finest 
needle  of  the  aspirator  is  indicated,  since  these  symptoms  may  be  due 
to  a  hsematoma,  which,  if  allowed  to  remain,  may  produce  total  dis- 
organization of  the  testicle.  The  aspirating  needle  should  be  thrust 
in  at  the  most  painful  spot  or  into  any  area  of  obscure  softening  or 
fluctuation,  if  this  can  be  detected.  If  the  needle  shows  that  there  is 
an  encysted  blood  effusion,  this  should  be  opened,  the  blood  evacu- 
ated, and  the  cavity  drained. 

Haematocele  of  the  cord  .may  be  diffuse  or  encysted. 

Diffuse  h^ematocele  is  usually  due  to  rupture  of  a  vein  from  direct 
traumatism  or  sudden  increase  of  intra-abdominal  pressure.  There 
forms  quickly  a  doughy,  sausage-shaped  tumor,  occupying  the  position 
of  the  cord,  and  entirely  obscuring  it.     This  tumor  is  not  translucent. 

In  the  chronic  form  of  diffuse  haematocele  of  the  cord  the  blood 
effusion  may  reach  enormous  dimensions.  It  is  characterized  by 
great  thickening  of  the  limiting  walls. 

Treatment. — This  has  for  its  object  the  limitation  of  effusion  and 
the  prevention  of  inflammatory  reaction.  The  patient  is  put  to  bed. 
A  layer  of  sterile  cotton  is  placed  over  the  cord,  and  a  crossed  of  the 
perineum  is  firmly  a-pplied.  If  in  twenty-four  hours  it  is  evident  that 
the  bleeding  has  ceased,  inflammatory  reaction  is  limited  by  evapo- 
rating lotions  or  the  ice-bag.  Should  bleeding  persist  in  spite  of 
pressure,  incision,  securing  the  bleeding  point,  and  closure  of  the 
wound  without  drainage  are  indicated. 

Encysted  hematocele  of  the  cord  is  due  to  hemorrhage  into  an 
encysted  hydrocele  or  to  the  encysting  of  a  hemorrhage  into  the  cord. 
It  begins  in  the  lower  part  of  the  cord,  forming  a  pyriform  tumor, 
with  the  base  down,  which  ultimately  may  become  merged  with  the 
epididymis  and  testis. 

The  diagnosis  is  suggested  by  the  history  of  the  tumor,  especially 
its  origin,  and  the  absence  of  translucency. 

Treatment. — Incision,  evacuation  of  clots,  and  decortication  or 
complete  removal  of  the  sac  are  indicated. 


700  GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 

Loose  Bodies  in  the  Tunica  Vaginalis. — It  sometimes  happens 
that  on  palpation  of  the  testis  a  rather  hard  body,  about  the  size  of  a 
kidney-bean  or  smaller  than  this,  may  be  felt  moving  freely  under  the 
finger.  This  body  is  smooth  and  elastic  ;  its  motion  may  be  limited, 
or  may  be  so  free  that  the  body  can  be  pushed  into  any  portion  of 
the  vaginal  sac.  There  is  usually  a  moderate  degree  of  hydrocele  of 
a  thickish  consistence.  These  bodies  may  be  cysts  with  thick  walls, 
sometimes  exhibiting  calcareous  degeneration,  the  remains  of  foetal 
structures  ;  they  originate  beneath  the  tunica  vaginalis,  and  become 
pedunculated  and  finally  free,  the  pedicle  rupturing.  Floating  fibroid 
and  cartilaginous  bodies  are  also  found ;  these  grow  from  the  sub- 
serous connective  tissue  and  may  become  detached  and  lie  loose  in  the 
cavity.     They  are  generally  small  and  multiple. 

Symptoms. — These  bodies  are  commonly  found  accidentally,  and 
cause  no  symptoms  beyond  a  moderate  hydrocele,  with  which  they 
are  usually  associated.  If  they  cause  pain  and  acute  vaginalitis,  or 
if  they  are  encountered  during  the  radical  cure  of  hydrocele,  they 
should  be  removed. 

NEURALGIA  OF  THE  TESTICLES. 

Reference'  has  been  made  already  to  the  intense  pain  which 
accompanies  inflammatory  conditions  of  the  testicle  and  epididymis. 
There  may,  however,  be  a  pain  equally  severe  which  occurs  without 
apparent  cause  in  testicles  showing  no  evidence  of  disease.  This 
pain  may  be  in  the  testicle  or  may  shoot  from  this  region  along  the 
cord  in  various  directions.  It  may  be  continuous  or  regularly  or 
irregularly  intermittent.  It  is  symptomatic  of  what  Cooper  called 
"  irritable  testicle,"  and  is  sometimes  observed  in  hysterical  patients. 
Exceptionally  the  aura  of  true  epilepsy  takes  the- form  of  neuralgia  of 
the  testis. 

Many  cases  supposed  to  be  purely  neuralgic  are  dependent  upon 
distinct  lesion.  Thus,  the  pain  may  be  excited  by  tumors,  such  as 
fibromata  or  myomata,  or  by  parenchymatous  blood-cysts,  or  by  the 
congestions  incident  to  varicocele. 

The  only  symptom  of  the  neuralgia  is  pain.  This  may  be  ago- 
nizing in  its  intensity,  and  may  be  associated  with  tonic  or  clonic 
spasm  of  the  cremaster  muscle.  The  testicle  is  extremely  sensitive, 
even  friction  of  the  garments  or  the  slightest  touch  causing  severe 
suffering.  During  the  paroxysms  of  pain  the  testicle  may  become 
hard  and  the  vessels  of  the  cord  congested.  The  neuralgia  may  be 
dependent  upon  traces  of  a  previous  inflammation,  the  presence  of 
a   hernia,  or  certain   systemic  conditions,  as  gout,  rheumatism,  or 


NEURALGIA   OF   THE    TESTICLES.  70] 

toxaemia.  We  believe  that  careful  examination  will  show  that  the 
majority  of  cases  are  in  part  due  to  a  varicose  condition  of  the  sper- 
matic veins.  It  is  true  that  varicocele  may  attain  enormous  dimen- 
sions and  yet  cause  no  pain.  Even  slight  dilatation  may,  however, 
occasion  marked  symptoms  in  those  who  are  hereditarily  neurotic. 

Treatment. — The  first  thought,  in  treating  this  affection,  should 
be  to  exclude  organic  lesions,  such  as  blood-cyst,  tubercle,  hernia,  or 
varicocele  ;  when  it  is  evident  that  pain  is  not  dependent  upon  a  local 
condition  which  may  be  remedied  by  operation,  palliative  treatment 
is  indicated.  A  great  number  of  external  applications  and  internal 
remedies  have  been  used,  and  often  successfully.  It  must  be  con- 
fessed that  certain  cases  resist  every  form  of  treatment.  Among  the 
most  serviceable  therapeutic  measures  are  the  pressure  suspensory 
bandage,  local  applications  of  heat  and  cold,  counter-irritation,  freez- 
ing the  overlying  skin  with  ethyl  chloride,  blisters,  galvanism,  and  the 
ice-bag.  Internally  there  may  be  given  aconitine  in  full  doses,  quinine, 
antipyrin,  acetanilid,  exalgin,  valerian,  and  hyoscine.  The  general 
treatment  should  be  hygienic  and,  if  indicated,  anti-rheumatic. 


CHAPTER   XIX. 

INJURIES    AND    DISEASES    OF    THE    SPERMATIC    CORD    AND    SEMINAL    VESICLES. 

Attention  has  been  called  already  to  certain  anomalies  of  the 
cord.  Thus,  this  structure  may  be  absent,  even  though  the  testicle  is 
in  its  normal  place,  or  the  two  cords  may  be  fused,  or  one  cord  may 
be  double.  The  vas  may  communicate  directly  with  the  ureter,  as  is 
normal  at  one  period  in  foetal  life,  or  may  be  entirely  wanting  in  its 
prostatic  portion,  or  may  be  fused.  The  single  duct  may  open  into 
the  utricle,  or  may  continue  by  a  distinct  passage  to  the  glans  penis. 

Contusions  and  Wounds  of  the  Cord. — Contusions  rarely 
cause  injury  other  than  an  acute  hsematocele,  the  blood  which  is 
poured  out  from  the  ruptured  veins  being  limited  by  the  fibrous 
sheath  of  the  cord,  thus  forming  a  sausage-shaped  tumor  which  may 
extend  from  the  testicle  to  tbe  internal  ring  and  beyond,  filling  the 
inguinal  canal.  It  is  usually  associated  with  hemorrhage  into  the 
scrotal  tissue,  which  may  completely  mask  it. 

Treatment. — Rest,  elevation,  pressure,  and  the  apphcation  of  ice 
during  the  bleeding  stage,  followed  by  evaporating  liniments,  and 
possibly  massage  for  the  purpose  of  hastening  absorption,  outline  the 
treatment. 

Wounds  of  the  cord  are  necessarily  attended  by  free  bleeding, 
for  the  arrest  of  which  ligatures  are  required.  If  the  deferent  canal 
is  divided,  its  continuity  may  be  restored  by  the  direct  apposition  of  the 
thick  walls  by  suture.  Division  of  the  vas  is  not  necessarily  followed 
by  atrophy  of  the  testicle,  even  though  the  operation  for  the  restora- 
tion of  the  continuity  of  the  canal  is  not  performed.  When  the  sper- 
matic artery  is  divided,  and  particularly  when  the  plexus  of  nerves 
supplying  the  testicle  is  extensively  injured,  atrophy  or  gangrene  is 
extremely  likely  to  result. 

Inflammation  of  the  Cord. — Funiculitis  or  inflammation  of  the 
cord  may  be  acute  or  chronic. 

Acute  funiculitis  may  arise  from  extension  of  a  posterior  ureth- 
ritis along  the  vas,  or  from  phlebitis,  especially  that  dependent  upon 
rheumatism.  Two  forms  of  the  affection  have  been  described, 
serous  funiculitis,  or  acute  hydrocele,  and  phlegmonous  funiculitis.  It 
is  possible  that  serous  funiculitis  (diffuse  hydrocele),  which  forms  a 
rounded,  sausage-shaped,  pitting,  translucent   tumor   occupying  tha 

702 


INJUEIES   AND   DISEASES  OE   THE   SPEKMATIC   COED. 


703 


Fig.  214. 


position  of  the  cord,  is  in  reality  sometimes  an  encysted  hydrocele. 
It  occurs  as  a  complication  of  gonorrhoea  or  rheumatism. 

Phlegmonous  funiculitis  is  usually  traumatic  in  origin.  It  is  also 
caused  by  gonorrhceal  inflammation  of  the  vas  and  by  septic  phlebitis. 
The  sausage-shaped  tumor  is  extremely  tender,  and  may  develop  with 
symptoms  characteristic  of  strangulated  hernia.  Should  the  infil- 
trate suppurate,  it  is  likely  to  invade  the  peritoneal  cavity  in  its 
upv^ard  extension. 

Chronic  funiculitis  is  usually  tubercular. 

Treatment.- — ^Acute  funiculitis  is  treated  by  rest,  elevation,  and  the 
application  of  cold,  preferably  in  the  form  of  evaporating  lotions. 
Should  the  swelling  be  so  marked  as  to  threaten  the  vitality  of  the 
testis,  incision  and  drainage  are  indicated. 

Tumors  of  the  Cord. — Lipoma  is  the  most  frequent  tumor  of 
the  cord.  It  may  develop  entirely  in  the  scrotal  portion  of  this 
structure,  or  may  extend  along  the  inguinal  canal  and  into  the  pelvis. 
Lipoma  may  reach  a  large  size:  Wilms  reports  one  which  weigned 
twenty  pounds.  In  the  course  of  its 
growth  the  hpoma  incidentally  becomes 
distinctly  lobulated,  simulating  malignant 
disease,  penetrating  between  the  struc- 
tures of  the  cord  (Fig.  214),  and  making 
entire  removal  without  sacrifice  of  the 
testicle  impossible.  Hence  the  impor- 
tance of  early  treatment. 

Lipoma  may  undergo  myxoid  degen- 
eration, and  exhibit  a  tendency  to  recur 
on  removal. 

The  symptoms  are  those  of  a  pain- 
less, slow,  somewhat  irregular,  slightly 
translucent,  soft  but  lobulated  growth  in 
the  course  of  the  cord. 

The  diagnosis  from  omental  hernia 
may  be  impossible  without  exploratory 
ipcision.  Even  then  the  surgeon  may  be 
in  doubt,  but  may  be  guided  by  remem- 
bering that  the  fatty  growth  of  an  epip- 
locele  is  within  the  peritoneal  sac  and  is  often  adherent  to  it.  The 
history  of  lipoma  differs  from  that  of  hernia,  since  it  gradually  de- 
velops along  the  course  of  the  cord,  grows  upward,  is  not  reducible, 
and  until  it  involves  the  inguinal  canal  will  not  give  an  impulse  on 
coughing. 


Lipoma  of  the  cord.    (Pean.) 


704 


GENITO-URINAKY   DISEASES  AND   SYPHILIS. 


Fig.  215. 


Treatment. — Early  operation  is  always  indicated,  since  when  the 
tumor  is  small  it  may  be  entirely  removed  without  sacrificing  the 
cord.  When  the  tumor  has  reached  a  large  size  and  it  is  impossible  to 
dissect  it  free  from  the  structures  of  the  cord,  castration  is  indicated. 
Myoma  is  rare.  It  may  be  found  together  with  lipoma,  giving  a 
semi-malignant  character  to  an  otherwise  benign  tumor. 

Sarcoma  and  carcinoma  are  more  frequent  than  myxoma.     They 
both  cause  metastasis  and  develop  as  do  similar  tumors  in  other 

regions  of  the  body.     They  often  undergo 
cystic  degeneration. 

The  treatment  is  castration,  with  re- 
moval of  as  much  of  the  cord  as  possible. 
Tuberculosis. — In  the  course  of  gen- 
ito-urinary  tuberculosis  the  vas  is  frequently 
infiltrated.  This  is  nearly  always  second- 
ary to  involvement  of  the  epididymis  or 
the  prostate.  Exceptionally  nodules  first 
develop  in  the  vas,  the  epididymis  being 
apparently  healthy.  Reclus  has  observed 
two  such  cases  :  in  one  the  nodule  involved 
the  cord  at  the  position  of  the  external 
ring,  in  the  other  it  was  within  the  inguinal 
canal. 

In  the  rare  cases  of  primary  involve- 
ment of  the  vas  the  appropriate  treatment 
would  be  excision  of  the  affected  portion 
of  the  canal,  followed  by  an  anastomosis 
by  Van  Hook's  method. 

Varicocele,  or  dilatation  and  elonga- 
tion of  the  veins  of  the  spermatic  cord 
(Figs.  215,  216),  is  most  frequent  in  early 
manhood, — that  is,  from  about  the  fifteenth 
to  the  twenty-fifth  year ;  it  is  rare  in  in- 
fancy ;  in  old  age  it  is  of  moderate  devel- 
opment and  causes  little  inconvenience. 
The  veins  of  the  cord  are  especially  prone  to  dilatation  and  elongation 
from  the  fact  that  their  valves  are  insufficient,  and  hence  there  is  a 
long  column  of  blood  to  be  supported.  The  disease  usually  affects  the 
left  testicle  (ninety  per  cent,  of  cases),  possibly  because  the  vein,  in- 
stead of  passing  obliquely  into  the  vena  cava,  as  on  the  right  side, 
enters  the  renal  vein  almost  at  right  angles  to  its  long  axis,  and,  more- 
over, lies  behind  the  rectum. 


Varicocele. 


(Osborii.)    Muiiod  and 
Terrillon. 


INJUEIES  AND   DISEASES   OF   THE   SPEEMATIC   CORD.        705 

The  veins  composing  the  spermatic  plexus  can  be  ranged  in  three 
groups,  the  most  anterior  of  which  has  in  its  midst  the  spermatic 
artery,  the  middle  the  vas  deferens,  and  the  posterior  those  veins 
vvrhich  pass  upward  from  the  tail  of  the  epididymis.  The  anterior 
group  is  the  one  first  affected,  or,  if  the  dilatation  affects  all  the 
veins,  is  most  extensively  involved.  Besides  the  mechanical  condi- 
tions favoring  the  development  of  varicocele,  there  are  other  causes, 
such  as  prolonged  standing  or  walking,  violent  muscular  exertion, 
masturbation,  sexual  excess,  traumatism,  inflammation,  gonorrhoeal 


Fig.  216 


Dilatation  of  the  veins  in  a  marked  case  of  varicocele.    (Kocher.) 


epididymitis,  and  tumor-formations  in  the  abdominal  cavity,  par- 
ticularly swelling  of  the  lumbar  lymphatic  glands  or  involvement  of 
the  kidneys.  Hernia,  heredity,  constipation,  have  all  been  assigned 
as  etiological  factors,  but  their  influence  is  not  proved.    Billroth  states 


700  GENITO-UKINAET  DISEASES   AND  SYPHILIS. 

that  varicocele  is  due  to  a  diathesis  which  first  affects  the  vessels  of 
the  pampiniform  plexus,  and  later  those  of  the  rectum  and  the  leg. 

Symptoms. — These  may  be  direct  or  reflex.  The  direct  symptoms 
are  as  follows :  The  scrotum  of  the  affected  side  is  filled  with  a  tor- 
tuous mass  of  veins,  sometimes  visible  through  the  skin,  and  feeling 
like  a  bundle  of  worms.  The  tumor  formed  by  these  veins  partly  or 
completely  disappears  on  lying  down,  but  reappears  on  standing  up, 
increasing  in  size  gradually  from  below  upward.  Pressure  exerted 
over  the  inguinal  ring  does  not  prevent  the  appearance  of  the  tumor. 
The  scrotum  is  elongated,  dusky  purphsh  in  color,  and  in  advanced 
cases  the  testicle  of  the  side  involved  is  often  markedly  atrophied. 

The  reflex  symptoms  are — (1)  pain  in  the  testicle,  the  lumbar  re- 
gion, the  hypogastrium,  and  often  in  the  penis.  It  bears  no  relation 
to  the  size  of  the  tumor.  It  may  be  agonizing  or  simply  harassing. 
(2)  Sexual  neurasthenia,  characterized  by  mental  depression,  sexual 
weakness  or  impotence,  headache,  nervousness,  lack  of  power  of 
concentrating  the  mind,  and  other  vague  general  symptoms. 

Varicocele  may  simulate  omental  hernia.  The  hernia  has  not, 
however,  the  characteristic  feehng  of  a  bundle  of  worms  ;  if  reduced  it 
will  not  recur  when  pressure  is  made  over  the  external  inguinal  ring, 
and  it  gives  a  much  more  distinct  succussion  on  coughing  than  does 
varicocele.     The  development  of  the  two  affections  is  quite  different. 

Prognosis. — Varicocele  observed  in  young  men  subject  to  pro- 
longed and  ungratified  sexual  excitement  is  usually  cured  by  marriage, 
or,  at  least,  it  ceases  to  give  trouble  afterwards.  If  moderate  in  degree 
it  has  no  marked  tendency  to  increase,  causes  little  pain,  and  does 
not  appreciably  alter  the  nutrition  of  the  testicle.  Quenu  states  that 
owing  to  the  dilatation  of  the  veins  of  the  nerves  there  occurs  a  peri- 
phlebitis and  neuritis,  which  would  account  for  both  pain  and  atrophy. 
Only  when  varicocele  is  so  pronounced  that  circulation  is  materially 
interfered  with  does  atrophy  of  the  testicle  result.  Spontaneous  cure 
seldom  occurs,  except  in  those  rare  acute  cases  which  develop  with 
mild  inflammatory  symptoms  in  consequence  of  strain  or  exposure. 
There  is  one  form  of  varicocele  frequently  noted  in  old  men,  due  to 
dilatation  of  the  lower  portion  of  the  posterior  group  of  veins  and 
completely  masking  the  lower  portion  of  the  epididymis.  This  is 
frequently  followed  by  sclerosis  of  the  lower  testicular  segment. 
Treatment. — Treatment  may  be  palliative  or  radical. 
Palliative  treatment  consists  in  the  proper  regulation  of  the  bowels, 
the  avoidance  of  all  exciting  causes,  such  as  violent  muscular  efforts 
or  prolonged  standing,  the  daily  application  of  cold  douches  to  the  skin 
overlying  the  dilated  veins,  and  the  wearing  of  a  properly  fitted  sus- 


INJURIES   AND   DISEASES   OF    THE   SPERMATIC    CORD.        707 

pensory  bandage.  This  treatment  is  indicated  when  the  varicocele  is 
moderate  in  size,  when  the  nutrition  of  the  testicle  is  not  interfered 
with,  and  when  the  reflex  symptoms  are  not  pronounced. 

Radical  treatment  is  indicated  when  the  varicocele  is  progressive 
and  is  well  developed,  when  beginning  atrophy  of  the  testicle  is  observ- 
able, and  when  the  reflex  symptoms,  particularly  the  sexual  neuras- 
thenia, are  pronounced. 

Excision  of  the  affected  veins  is  best  performed  under  ether, 
though  eucaine  ansesthesia  makes  it  almost  painless.  The  operator 
by  palpation  finds  the  upper  portion  of  the  vas  and  presses  it  back- 
ward and  inward  away  from  the  affected  veins.  An  assistant  stand- 
ing to  the  left  of  the  patient  makes  firm  pressure  by  means  of  the 
thumb  and  fingers  of  the  right  hand  at  the  point  which  will  keep  the 
vas  back  and  the  enlarged  veins  forward.  The  surgeon,  passing  his 
fingers  lower  down,  again  separates  the  vas  from  the  veins,  and  the 
assistant,  placing  the  palmar  surface  of  the  left  hand  beneath  the 
scrotum,  presses  firmly  with  the  thumb  and  fingers,  keeping  the  lower 
part  of  the  vas  away  from  the  group  of  dilated  veins.  By  slight  ten- 
sion with  the  left  hand  the  skin  of  the  scrotum  is  made  taut.  The 
surgeon  makes  a  longitudinal  incision  two  inches  in  length  over  the 
most  prominent  part  of  the  varicocele,  dividing  the  skin,  dartos,  and 
fibrous  investment  of  the  cord  ;  through  each  lip  of  this  wound  is 
passed  a  short  thread,  the  two  ends  of  which  are  seized  with  haemo- 
static forceps ;  the  weight  of  the  instruments  retracts  the  borders  of 
the  incision,  thus  facilitating  subsequent  manipulations.  The  veins 
are  freed  by  blunt  dissection  for  two  or  three  inches  of  their  course, 
and  an  aneurism  needle,  threaded  with  catgut,  is  passed  beneath  the 
entire  group  at  the  lower  end  of  the  incision  ;  the  needle  is  unthreaded 
and  withdrawn  ;  another  needle,  similarly  threaded,  is  passed  beneath 
the  veins  at  the  upper  end  ;  thus  they  are  included  in  two  catgut  loops 
separated  from  each  other  by  an  interval  of  at  least  two  inches.  These 
ligatures  are  tied  tightly  with  a  triple  knot,  and  each  is  left  with  one 
long  end.  The  intermediate  portion  of  the  veins  is  then  cut  out  with 
scissors,  and  the  stumps  are  apposed  by  tying  the  long  ends  of  the 
ligatures  together.  This  shortens  the  cord,  and  thus  raises  the  testicle. 
The  skin  wound  is  closed  without  drainage. 

In  certain  cases  where  the  scrotum  seems  to  be  unusually  lax,  ex- 
cision of  the  superfluous  skin  and  dartos  is  indicated.  This,  if  under- 
taken, should  be  radical.  Enough  skin  should  be  taken  away  so  that 
the  flaps  are  stretched  taut  over  the  testes  when  the  wound  is  closed. 
Absolute  haemostasis  should  be  secured,  and  the  sutures  must  be  so 
placed  that  the  skin  is  not  inverted.     To  prevent  recurrence  it  is  at 


708 


GENITO-URINARY   DISEASES   AND   SYPHILIS. 


times  necessary  to  combine  ligation  and  resection  of  the  cord  with 
resection  of  the  scrotum. 

When  the  posterior  group  of  veins  is  markedly  involved,  forming 
a  doughy  tumor  behind  and  below  the  epididymis,  these  vessels 
should  be  ligated  and  excised,  either  through  a  separate  incision  or 
through  the  wound  resulting  from  resection  of  the  scrotum. 

The  results  of  the  operation  are  usually  satisfactory.  Exception- 
ally atrophy  or  even  gangrene  of  the  testicle  follows  ligation  of  the 
veins  of  the  cord.  Sometimes  the  reflex  phenomena  are  unrelieved 
or  even  exaggerated,  possibly  because  the  neuritis  originally  caused 
by  varicocele  is  progressive. 


THE   SEMINAL  VESICLES. 
The  anatomy  of  the  seminal  vesicles  has  already  been  briefly  out- 
lined.    These  glands  form  two  lobulated  pouches,  lying  at  the  base 


Fig.  217. 


Fig.  218. 


Right  seminal  vesicle,  posterior  surface,  dis- 
sected out.  1,  deferent  canal,  with  (1')  the  am- 
pulla ;  2,  seminal  vesicle,  with  (3)  lateral  pro- 
longations, (4)  csecal  dilatations,  and  (5)  parietal 
projections ;  6,  union  of  the  vesicle  with  the  vas ; 
7,  ejaculatory  duct ;  xx  marks  the  position  of 
the  posterior  extremity  of  the  undissected  vesicle. 
(Testut.) 

a  quarter  of  an  inch  in  thickness, 
which  the  vas  empties  just  before 


Long  section  of  dilated  seminal  vesicle. 

(Sappey.) 

of  the  bladder.  The  walls  of 
these  pouches  are  thin,  and  if 
carefully  dissected  can  be  partly 
extended  in  the  form  of  an  irreg- 
ular tube,  with  caecal  projections 
and  diverticula.  (Fig.  217.)  The 
inner  surface  is  irregularly  saccu- 
lated. (Fig.  218.)  The  vesicles 
are  enclosed  in  a  dense  fascia, 
which  passes  from  the  walls  of  the 
bladder  to  the  posterior  surface 
of  the  prostate.  The  vesicles  in 
their  convoluted  form  are  about 
two  inches  in  length,  three- 
quarters  of  an  inch  in  width,  and 
They  terminate  in  a  duct  into 
the  latter  enters  the  substance 


INJUKIES   AND   DISEASES   OF    THE    SEMINAL   VESICLES.      709 


of  the  prostate.  The  lower  inner  portion  of  each  vesicle  is  usually 
adherent  to  the  wall  of  the  vas,  making  a  dissection  at  this  point 
difficult.  (Fig.  219.)  Above,  the  two  struc- 
tures are  entirely  separated,  being  enclosed  in 
distinct  compartments  of  the  dense  fascia 
which  passes  from  the  upper  posterior  wall 
of  the  bladder  to  the  base  of  the  prostate. 
The  upper  extremities  of  the  seminal  vesicles 
correspond  to  about  the  point  of  entrance  of 
the  ureters  into  the  bladder,  and  are  in  close 
relation  with  the  peritoneum,  which  is  here 
reflected  from  the  posterior  wall  of  the  blad- 
der to  the  rectum.  Within  the  fascia  which 
includes  in  separate  compartments  the  sem- 
inal vesicles  and  the  vasa  are  found  many  mus- 
cular fibres,  apparently  originating  from  the 
bladder- wall  and  the  posterior  surface  of  the 
prostate.  (Fig.  220.)  These  fibres  are  par- 
ticularly abundant  along  the  under  and  outer 
surfaces  of  the  vesicles.  The  vesicles  are  some- 
what pear-shaped,  the  narrow  end  running 
downward  and  inward.  As  is  the  case  with 
all  the  sexual  organs,  they  vary  greatly  in  size, 
bearing  no  fixed  relation  to  the  development 
of  either  the  individual  or  the  other  organs, 
or  even  to  one  another.     Thus  it  is  not  un- 


Deferent  canal  and  seminal 
vesicle.  A,  longitudinal,  B, 
transverse  section ;  1,  deferent 
canal ;  2,  its  ampullated  por- 
tion ;  3,  seminal  vesicle  with 
(3')  pouches ;  4,  terminal  por- 
tion ;  5,  ejaculatory  duct.  (Tes- 
tut.) 


Fig.  220. 


Horizontal  section  of  the  bladder  and  seminal  vesicles  passing  through  the  lower  orifice  of  the 
ureters.  1,  inner  surface  of  the  bladder ;  2,  2',  ureters ;  3,  intra-ureteric  ridge  ;  4,  bas-fond ;  5,  seminal 
vesicles;  6,  deferent  canals  (ampullated  portion) ;  7,  interdefereutial  triangle  ;  8,  rectum;  9,  prostato- 
peritoneal  aponeurosis  ;  10,  musculo-fibrous  tissue  enveloping  the  vasa  and  vesicles ;  11,  11,  cellular 
tissue  of  the  pelvis.    (Testut.) 


710 


GENITO-UEINAPvY   DISEASES   AND   SYPHILIS. 


common  to  find  one  vesicle  twice  or  thrice  the  size  of  its  fellow, 
without  obvious  reason  for  this  apparent  asymmetry.  The  portion  of 
the  bladder  lying  between  the  inner  borders  of  the  two  seminal  vesicles 
and  limited  above  by  a  transverse  line  connecting  the  two  bases  cor- 
responds to  the  position  of  the  vesical  trigonum.  The  vesicles  have 
rather  thin  walls,  made  up  of  fibrous  and  muscular  tissue,  lined  with 
mucous  membrane  in  which  are  found  many  tubular  glands. 

The  ejaculatory  ducts,  formed  by  a  continuation  of  the  seminal 
vesicles  arid  the  vasa  deferentia,  enter  the  substance  of  the  posterior 


Fig.  221. 


Fig.  222. 


Relations  at  posterior  surface  of  bladder. 
(Testut.) 


prostatic  isthmus,  passing  down- 
ward and  forward,  and  opening 
in  the  borders  of  the  utricle  or 
within  this  cavity.  The  diame- 
ter of  their  orifices  is  one-half 
millimetre,  while  at  their  origin 
it  is  three  times  as  great.  (Fig. 
222.) 

The  function  of  the  seminal 
vesicles  is  probably  entirely  secre- 
tory. Examination  usually  shows 
a  few  spermatozoa,  but  never  a 
quantity  of  semen  sufficient  to 
suggest  that  this  convoluted  tube 
1-3  a  receiver  and  storer  of  the 
secretion  from  the  testicle,  such, 
for  the  secretion  of  the  liver. 


Posterior  urethra  exposed  by  splitting  its  upper 
wall.  1,  vesical  neck ;  2,  section  of  the  prostate 
and  the  urethral  sphincters ;  3,  section  of  the  mem- 
branous urethra ;  4,  section  of  the  spongy  urethra ; 
4',  bulb;  5,  5',  cavernous  bodies;  6,  verumonta- 
num,  with  (6')  orifice  of  the  utricle ;  7,  posterior 
wall  of  the  prostatic  urethra,  showing  glandular 
openings;  8,  right  ejaculatory  duct  exposed;  8', 
its  orifice ;  9,  Cowper's  gland ;  10,  its  duct  exposed  ; 
10',  opening  of  the  duct ;  11,  longitudinal  folds  of 
the  urethral  mucous  membrane;  12,  bulbar  cul- 
de-sac  ;  13,  narrowing  of  the  bulb  at  the  beginning 
of  the  membranous  urethra.    (Testut.) 

for  instance,  as  is  the  gall-bladder 


INJURIES   AND   DISEASES   OP   THE   SEMINAL   VESICLES.      711 

The  vesicles  receive  their  blood-supply  from  the  inferior  vesical 
and  middle  hemorrhoidal  arteries.  The  nerves  come  from  the  hypo- 
gastric plexus. 

Anomalies  of  the  Seminal  Vesicles. — The  seminal  vesicles 
may  be  absent.  In  this  case  there  is  usually  absence  of  the  testicles 
though  Tenon  and  others  have  reported  cases  of  bilateral  absence 
where  the  testicles  were  still  present ;  there  were,  however,  other 
deformities.  Unilateral  absence  has  been  noted  in  conjunction  with 
unilateral  malformations,  involving  structures  other  than  the  testicle 
or  the  cord.  Hunter  has  reported  fusion  of  the  vesicles,  the  ducts 
of  the  two  glands  uniting  and  ending  in  a  blind  pouch.  Multiple  vesi- 
cles have  been  observed.  Atrophy  of  the  vesicles  has  been  frequently 
noted  at  post-mortem  examination  and  quite  independent  of  any 
affection  of  the  urethra  or  the  testicles.  Communication  with  the 
ureter  also  has  been  observed,  this  condition,  which  obtains  during 
foetal  life,  having  persisted. 

The  ejaculatory  ducts  may  be  partially  wanting,  may  be  entirely 
absent,  or  may  be  fused ;  they  may  pass  directly  into  the  prostatic 
utricle,  or  may  continue  forward  into  a  canal  opening  at  some  point 
on  the  glans  penis,  this  condition  giving  rise  to  the  misconception  of  a 
double  urethra. 

Injuries  of  the  Seminal  Vesicles. — From  their  position  it  is 
evident  that  the  seminal  vesicles  are  well  protected  against  trauma- 
tism, except  that  which  is  so  extensive  that  other  lesions  overshadow 
in  importance  the  injuries  to  the  vesicles. 

In  the  event  of  the  wounding  of  a  vesicle  in  the  performance  of 
surgical  operations  on  the  bladder  the  consequences  would  not  be 
serious.  When  both  vasa  or  both  ejaculatory  ducts  are  divided  or 
torn  it  is  extremely  probable  that  sterility  will  result  from  obliteration. 
A  wound  of  the  seminal  vesicle  alone  is  of  minor  importance,  though 
it  is  conceivable  that  it  might  be  followed  by  fistula.  The  treatment 
of  wounds  of  the  seminal  vesicles  is  conducted  in  accordance  with 
general  principles. 

Vesiculitis  or  Spermatocystitis. — The  usual  cause  of  this 
affection  is  extension  of  gonorrhoeal  inflammation  into  the  congested 
seminal  vesicles.  It  may  be  due  also  to  infection  with  the  ordinary 
pus  microbes  and  perhaps  with  the  colon  bacillus.  There  is  some 
proof  of  the  possibility  of  its  production  by  masturbation,  excessive 
coitus,  or  direct  extension  from  the  bladder. 

Symptoms. — The  onset  of  acute  seminal  vesiculitis  is  characterized 
by  practically  the  same  symptoms  as  those  noted  in  describing  acute 
posterior   urethritis.     There  are  frequent,  straining,  painful   mictu- 


712  GENITO-UEINARY   DISEASES   AND   SYPHILIS. 

rition,  and  constant  or  shooting  pains  in  the  perineum,  hypogastric 
region,  and  anus  ;  the  pain  is  often  referred  to  the  hip-joint  and  sacro- 
iliac articulation  of  the  affected  side,  and  runs  down  the  outer  side 
of  the  leg.  Both  direct  and  reflected  pains  are  made  worse  by  mic- 
turition or  defecation.  At  times  there  are  retention  of  urine  and 
violent  rectal  tenesmus,  the  suffering  being  so  intense  that  an  opiate 
is  required.  Exceptionally  the  disease  is  ushered  in  with  the  ful- 
minant symptoms  of  an  acute  peritonitis.  There  are  vomiting, 
tympany,  constipation,  and  tenderness  over  the  whole  lower  belly- 
segment.  Persistent  erections  are  frequent ;  painful  emissions  of 
blood-stained  semen  are  not  uncommon. 

Rectal  examination  shows  at  once  a  hot,  tender,  obscurely  fluc- 
tuating mass  passing  upward  and  outward  from  the  lateral  lobe  of  the 
prostate,  usually  about  the  size  of  the  thumb,  with  its  upper  limit 
beyond  the  region  of  the  examining  finger.  Usually  the  inflammatory 
swelling  causes  a  bulging  of  the  entire  space  lying  above  the  prostate 
suggesting  to  the  examining  finger  an  enlargement  of  the  gland.  There 
is  usually  pronounced  fever. 

Sometimes  acute  vesiculitis  develops  insidiously.  The  patient  is 
not  confined  to  bed,  but  may  complain  of  shooting  intermittent  pains 
of  moderate  severity  in  the  perineum,  with  rheumatic  aches  felt  in 
the  hip,  sacro-iliac  joint,  rectum,  and  perineum,  or  down  the  outer 
and  inner  surfaces  of  the  leg. 

Diagnosis. — The  diagnosis  of  acute  seminal  vesiculitis  is  founded 
on  rectal  examination.  When  practicable  this  should  be  conducted 
with  a  fairly  full  bladder,  the  patient  leaning  forward  over  a  chair, 
with  the  legs  slightly  separated ;  or  he  may  be  put  in  the  lithotomy 
position  and  the  base  of  the  bladder  outlined  by  bimanual  palpa- 
tion, the  fingers  of  one  hand  being  placed  deeply  behind  the  pubis, 
while  the  index  of  the  other  hand  is  introduced  into  the  rectum. 
Palpation  is  the  only  means  of  making  a  differential  diagnosis  from 
prostatitis,  and  it  must  be  noted  that  it  does  not  enable  the  surgeon  to 
distinguish  definitely  between  spermato-cystitis  and  inflammation  of" 
the  ampulla  of  the  vas.  In  both  cases  the  swelling,  at  least  during 
the  acute  stage,  is  mainly  due  to  infiltration  of  the  intertubular  and 
periglandular  connective  tissue.  When  both  sides  are  involved  this 
infiltration  may  be  so  extensive  as  to  form  a  large  projecting  mass 
more  prominent  than  the  prostate  and  extending  from  the  outer 
border  of  one  vesicle  to  that  of  the  other,  completely  masking  the 
base  of  the  bladder.  This  condition  is  often  mistaken  for  acute 
prostatitis,  but  careful  palpation  will  outline  the  prostate  and  show 
that  it  is  normal  in  size.  Usuafiy  the  infiltration  is  not  so  extensive, 
the  inflammation  when  bilateral  forming  two  distinct  masses.     The 


INJUKIES   AND   DISEASES   OF   THE   SEMINAL   VESICLES.      713 

pain  referred  to  the  hip-joint  has  seemed  to  us  characteristic  of 
involvement  of  the  vesicles. 

Seminal  vesiculitis  has  been  mistaken  for  appendicitis,  and  the 
symptoms  may  be  identical,  A  history  of  urethral  discharge  would 
suggest  a  rectal  examination  which  would  clarify  the  diagnosis. 

Prognosis. — So  far  as  cure  is  concerned,  the  prognosis  must  be 
guarded.  Suppuration  once  established  in  the  convoluted  tubule 
which  makes  up  the  bulk  of  this  gland  is  difficult  to  cure,  since  its 
duct  of  entrance  is  so  narrow  that  it  is  impossible  to  reach  the  dis- 
eased surfaces  with  any  form  of  local  medication.  So  far  as  recovery 
from  immediate  symptoms  is  concerned,  the  prognosis  is  extremely 
favorable,  the  disease  usually  undergoing  partial  spontaneous  resolu- 
tion whether  treatment  is  adopted  or  not.  There  is,  however,  always 
a  possibility  of  periglandular  suppuration,  with  the  formation  of  an 
abscess,  which  may  rupture  into  the  rectum,  the  bladder,  or  the  peri- 
toneal cavity.  The  inflammation  frequently  travels  backward  along 
the  vas,  causing  epididymitis. 

The  usual  termination  of  the  affection  is  a  chronic  vesiculitis, 
which  causes  either  no  symptoms  or  those  of  urinary  or  genital  irri- 
tability, and  which  has  an  ultimate  tendency  to  recovery,  though  this 
may  take  months  or  years. 

Chronic  Vesiculitis, — This  is  the  usual  termination  of  acute  in- 
flammation. All  the  causes  of  pelvic  engorgement  predispose  to  its 
development ;  its  indefinite  prolongation  is  probably  due  to  a  stric- 
tured  condition  of  the  ejaculatory  duct,  which  may  be  completely 
obliterated. 

Symptoms. — The  symptoms  of  chronic  vesiculitis  are  practically 
those  of  chronic  posterior  urethritis, — i.e.,  the  patient  is  subject  to 
irregular  and  apparently  causeless  attacks  of  frequent,  urgent  urina- 
tion ;  he  suffers  from  a  gleet,  which  is  also  subject  to  exacerbations 
and  remissions,  or  may  light  up  after  each  intercourse  ;  mild  attacks 
of  epididymitis  develop  occasionally ;  there  is  often  alteration  in  the 
sexual  power  and  appetite,  and  frequently  there  are  developed  pro- 
nounced symptoms  of  sexual  neurasthenia,  with  pains  referred  to  the 
back,  hypogastrium,  and  thighs. 

Diagnosis. — The  diagnosis  of  chronic  vesiculitis  is  founded  upon 
rectal  palpation  and  examination  of  the  urine  passed  in  three  por- 
tions. The  patient  first  urinates  what  he  judges  to  be  a  third  of  the 
contents  of  the  bladder ;  the  seminal  vesicles  are  then  milked,  and 
the  patient  again  urinates,  in  two  portions ;  the  first  portion  passed 
after  milking  the  vesicles  will  of  course  contain  the  major  part  of  the 
fluid  discharge  from  these  glands. 


714  GEXITO-UKIJfAKY   DISEASES  AND   SYPHILIS. 

Still  another  method  of  determining  whether  or  not  pus  is  dis-. 
charged  from,  the  seminal  vesicles  is  by  irrigation  of  the  bladder  with, 
a  one-tenth  per  cent,  solution  of  methyl-blue  ;  this  should  be  thor- 
.oughly  washed  out  with  boric  acid  solution,  three  or  four  ounces  of 
which  should  be  left  in  the  bladder ;  the  seminal  yesicles  are  then 
milked, and  the  patient  is  directed  to  urinate;  pus  or  shreds  which 
are  unstained  mil  in  this  case  come  from  the  vesicles,  the  vasa,  the 
prostatic  follicles,  or  the  ejaculatory  ducts. 

Treatment  of  Vesiculitis. — The  prophylaxis  of  seminal  vesiculitis 
consists  in  adopting  every  possible  means  of  lessening  the  severity 
of  posterior  urethritis. 

It  is  evident  that  a  comparatively  slight  amount  of  inflammatory 
swelling  will  entirely  block  the  ejaculatery  duct  hence  u-ritating  injec- 
tions or  applications,  the  passage  of  instruments,  or  any  manipulation 
which  tends  to  aggravate  the  posterior  urethritis  should  be  avoided. 

Rest  in  bed,  elevation  of  the  pelvis,  rectal  injections  of  hot  or  cold 
saline  solution,  and  hot  sitz-baths  or  general  baths  are  especially  use- 
ful in  lessening  pain  and  congestion.  Usually  opium  and  belladonna 
suppositories  are  required. 

Chronic  vesiculitis  is  probably  dependent  upon  narrowing  of 
the  ejaculator\^  duct  and  consequent  imperfect  drainage  of  the  sup- 
porting sac. 

Belfield  notes  that  the  vas  deferens  can  easily  be  brought  by  the 
fingers  against  the  skm  of  the  scrotum  and  held  there  by  a  half-curved 
needle  passed  through  the  skin  under  the  vas.  By  a  transverse  or 
longitudinal  incision  into  the  vas  its  canal  is  opened  and  can  be  stitched 
to  the  skin  if  repeated  treatment  be  needed.  The  blunted  needle  of  a 
hypodermic  syringe  can  be  passed  into  this  minute  canal  and  thirty 
minims  of  any  desired  agent  injected ;  this  liquid  traverses  the  vas 
and  the  ampulla,  and  distends  the  seminal  vesicle.  Drainage  may  be 
facihtated  by  passing  a  fine  silkworm  or  horsehair  thread  along  the 
vas  to  the  ampulla. 

By  this,  direct,  repeated,  and  successful  medication  of  the  vas, 
ampulla,  and  seminal  vesicle  is  made  possible  and  without  a  serious 
operation. 

Belfield  has  cured  in  this  way  chronic  vesiculitis  v^lth  or  without 
a  gleety  discharge,  chronic  pus  infections  of  the  seminal  canal  of  the 
middle  aged  or  elderly,  usually  mistaken  for  enlarged  prostate  ;  recur- 
rent epididymitis,  and  acute  gonorrhceal  spermato-cystitis. 

Vesiculotomy  or  vesiculectomy  may  be  required  in  cases  not  yield- 
ing to  more  conservative  treatment  and  characterized  by  the  symptoms 


INJURIES   AND   DISEASES   OF   THE   SEMINAL  VESICLES.      715 

of  perineal  pain,  sexual  neurasthenia,  toxic  anaemia,  and  often  artic- 
ular rheumatism.  The  vesicle  is  reached  by  the  perineal  incision 
employed  for  the  enucleation  of  the  prostate.  By  blunt  dissection  the 
rectum  is  stripped  back,  the  region  of  the  vesicle  exposed,  the  sheath 
is  split,  and  it  is  either  curetted  or  enucleated,  a  cigarette  drain  being 
left  in  the  wound. 

Fuller's  treatment  by  massage  is  most  satisfactory  in  its  results  if  it 
be  applied  gently,  efficiently,  and  persistently.  Each  treatment  ex- 
presses from  the  vesicles  and  the  vasal  dilatations  the  muco-purulent 
contents.  The  patient  should  have  a  full  bladder.  With  his  knees 
straight  and  his  legs  moderately  separated  he  leans  forward,  bending 
the  body  almost  to  a  right  angle,  a.nd  supporting  himself  by  means  of 
a  chair  or  table.  The  operator  having  covered  his  examining  index- 
finger  with  a  well-lubricated  thin  rubber  cover,  passes  it  as  far  into  the 
rectum  as  possible,  thus  reaching  well  above  the  base  of  the  prostate 
and  distinctly  feeling  the  seminal  vesicles  if  they  be  enlarged.  By  a 
stripping  pressure  from  above  downward,  repeated  on  each  side  half  a 
dozen  times,  the  contents  of  the  vesicles  and  vasa  are  forced  through 
the  ejaculatory  ducts. 

This  treatment  should  be  repeated  twice  a  week,  and  should  not  be 
applied  with  sufficient  force  to  cause  immediate  pain  or  secondary 
inflammatory  reaction.  It  may  have  to  be  continued  for  many  months, 
and  must  always  be  supplemented  by  the  treatment  appropriate  to 
stricture  or  anterior  or  posterior  urethritis  when  these  conditions  are 
also  present.  Posterior  urethritis  is  practically  always  present  when 
the  seminal  vesicles  are  inflamed. 

Cystic  Swelling  of  the  Seminal  Vesicles. — Usually  as  the 
result  of  obstruction  of  the  ejaculatory  ducts,  conversion  of  the  whole 
vesicle  into  a  large  single  cyst  or  distention  of  one  or  more  of  its 
diverticula  may  occur ;  in  the  latter  case  the  enlargement  will  be 
made  up  of  a  number  of  smaller  cysts.  This  affection  may  run  its 
course  without  exhibiting  symptoms  other  than  those  incident  to 
chronic  inflammation  until  the  tumor  reaches  sufficient  size  to  pro- 
duce pressure  effects.  Cases  are  reported  in  which  the  cyst  reached 
enormous  dimensions.  In  one  case  quoted  by  Jacobson  ten  pints  of 
brown  serous  fluid  were  drawn  off.  After  two  tappings  the  cyst  did 
not  refill. 

The  diagnosis  is  based  on  rectal  palpation.  This  condition  can 
scarcely  be  differentiated  from  dermoid  cysts,  or  cysts  due  to  the 
rapid  development  of  the  remains  of  foetal  structures. 

Treatment. — The  treatment  in  such  cases  is  aspiration,  which  may 


716  GEI^ITO-UEINAKY   DISEASES   AND   SYPHILIS. 

be  twice  repeated.  In  case  this  fails,  permanent  drainage  may  be 
established  through  a  perineal  opening,  or  the  cyst  may  be  excised 
through  Zuckerkandrs,  Von  Dittel's,  or  Kraske's  incision.  (See  page 
717.) 

Spermatocystic  Concretions. — These  concretions  are  prob- 
ably formed  originally  because  of  obstruction  of  the  duct.  They  are 
made  up  of  spermatozoa,  mucus,  and  epithelium,  and  are  whitish  in 
color,  becoming  darker  with  age  and  undergoing  calcification.  Theii 
importance  lies  in  the  fact  that  they  may  occlude  the  ejaculatory 
duct,  thus  predisposing  to  sterility  and  rendering  the  cure  of  vesicu- 
litis impossible.  The  symptoms  are  pain  on  emission,  associated 
perhaps  with  the  symptoms  of  posterior  urethritis,  such  as  frequent 
urination  and  tenesmus. 

The  diagnosis  will  be  made  on  rectal  examination,  which  may 
demonstrate  one  or  more  hard  bodies  in  the  seminal  vesicles. 

Treatment  consists  in  breaking  up  these  concretions  by  pressure 
through  the  rectum  exerted  against  a  full-sized  sound  passed  into  the 
urethra. 

Tuberculosis  of  the  Seminal  Vesicles. — Tubercular  vesicu- 
litis is  nearly  always  secondary  to  involvement  of  the  prostate  and  the 
prostatic  urethra  or  the  epididymis,  though  clinically  cases  are  some- 
times observed  in  which  distinct  nodulation  of  the  vesicle  can  be  felt, 
the  prostate  being  apparently  healthy,  and  symptoms  pointing  to 
involvement  of  the  prostatic  urethra  being  absent. 

Tubercular  vesiculitis  is  characterized  by  the  formation  of  a  smooth, 
nodular,  hard  or  semi-fluctuating  tumor,  easily  detected  on  rectal  pal- 
pation. Both  seminal  vesicles  are  often  involved,  and  the  fibrous 
tissue  lying  between  them  is  infiltrated,  forming  a  mass  practically 
continuous  with  the  prostate  and  entirely  obscuring  the  base  of  the 
bladder,  which  normally  can  be  felt.  The  infiltrated  mass  is  rarely 
sensitive,  and  in  the  absence  of  involvement  of  the  prostatic  urethra 
causes  few  symptoms,  except  possibly  sexual  erethism,  bloody  semen, 
pain  during  or  after  ejaculation,  and  finally  sterility  and  impotence.  The 
infiltrate  often  breaks  down,  discharging  into  the  rectum  and  perineum. 

Tubercular  vesiculitis  is  essentially  an  affection  of  the  adult,  and  is 
usually  associated  with  involvement  of  the  prostate  and  epididymis. 
The  invasion  of  these  structures  is  often  simultaneous.  Clinically, 
we  have  many  times  noted  tubercular  vesiculitis  precede  by  weeks  or 
months  palpable  lesions  of  the  epididymis.  As  a  rule,  when  a  tuber- 
cular epididymitis  becomes  demonstrable,  the  vesicle  of  the  affected 
side  is  palpably  involved. 

Diagnosis. — The  diagnosis  of  tubercular  vesiculitis  is  founded  upon 


INJUEIES   AND    DISEASES   OF    THE   SEMINAL   VESICLES.      717 

the  discovery  of  an  irregular,  nodulated,  non-sensitive  growth  occu- 
pying the  position  of  the  seminal  vesicle,  and  associated  with  other 
symptoms  or  signs  of  genito-urinary  tuberculosis,  such  as  nodulation 
of  the  epididymis,  frequent  urination,  with  passage  of  blood  and  the 
finding  of  tubercle  bacilli  in  the  urine  or  the  semen.  The  ejaculation 
of  bloody  semen  in  the  absence  of  other  cause,  such  as  gonorrhoea] 
spermato-cystitis,  is  especially  characteristic. 

Tubercular  vesiculitis  occurring  in  the  course  of  gonorrhoeal  pos- 
terior urethritis  can  be  recognized  only  by  the  gradual  development 
of  a  nodular  semi-fluctuating  tumor.  The  termination  is  usually  in 
suppuration  and  the  formation  of  fistulous  tracts.  Spontaneous  cure 
has  been  reported  following  evacuation  of  abscesses. 

Treatment. — In  the  absence  of  symptoms,  and  when  nodulation  of 
the  epididymis  is  non-progressive,  treatment  may  be  confined  to  the 
general  hygienic,  dietetic,  and  medicinal  measures  apphcable  to  gen- 
eral tuberculosis.  As  in  all  inflammations  or  infiltrations  of  the  pelvic 
viscera,  regular  evacuations  from  the  bowels  are  of  extreme  impor- 
tance, and  as  a  means  of  lessening  local  congestion  the  urine  should 
be  rendered  unirritating  and  should  be  passed  at  regular  intervals. 
If  in  spite  of  careful  treatment  inflammation  is  steadily  extending,  ex- 
cision of  the  infiltrated  vesicle  is  indicated,  even  though  experience  has 
shown  that  a  few  of  these  cases  after  discharging  undergo  resolution. 

The  operation  of  excision  is  neither  difficult  nor  especially  danger- 
ous. The  objection  to  it  is  that  the  prostate  is  commonly  involved, 
that  the  bladder-w^alls  are  frequently  infiltrated,  and  that  complete 
removal  may  be  followed  by  fistula  formation. 

Excision  may  be  accomplished  through  Kraske's  incision  for  ex- 
cision of  the  rectum,  the  bowel  being  carried  to  one  side  after  partial 
excision  of  the  sacrum,  or  through  Zuckerkandl  or  Von  Dittel's  incision 
The  first  consists  in  a  semilunar  cut  extending  from  one  tuber  ischium 
to  the  other  and  sweeping  convexly  in  front  of  the  rectum.  The 
perineal  muscles  and  the  pubic  portion  of  the  levator  ani  muscles 
are  divided,  exposing  the  prostate  and  the  seminal  vesicles.  Von 
Dittel,  after  passing  a  catheter  into  the  bladder  and  filling  the  rectum 
with  gauze,  to  which  a  string  is  attached,  places  the  patient  in  the 
ventral  decubitus,  with  the  thighs  hanging  over  the  end  of  the  table. 
The  incision  is  then  made,  beginning  at  the  coccyx  and  carried 
directly  in  the  middle  line  to  the  middle  of  the  perineum,  making 
a  semicircular  sweep  around  the  anus.  This  cut  is  deepened,  the 
rectum  being  pushed  aside  until  the  seminal  vesicles  are  reached.  It 
must  be  remembered  that  the  latter  are  enclosed  in  a  tough,  fibro- 


718  GENITO-UEINAEY   DISEASES    AND  SYPHILIS, 

muscular  investment,  usually  covered  by  greatly  enlarged  veins.  Thii 
capsule  must  be  split  before  the  vesicles  can  be  enucleated. 

Baudet  and  Kendirjy  note  that  tuberculous  seminal  vesiculitis  often 
heals  spontaneously  after  castration.  If,  however,  the  organ  is  as  large 
as  the  last  joint  of  the  thumb,  has  formed  a  fistula,  or  occasions  diffi- 
culty with  stool,  it  should  be  removed  by  a  Y-shaped  perineal  incision. 

Malignant  growth  of  the  seminal  vesicle  is  always  secondary 
to  malignant  growth  of  the  adjoining  organs. 


CHAPTER   XX. 

INJURIES    AND    DISEASES    OF    THE    PROSTATE. 

Anatomy  of  the  Prostate. — The  prostate  is  a  genital  organ,  the 
bulk  of  which  is  made  up  of  glandular  tissue  and  smooth  muscular 
fibres.  As  is  the  case  with  all  genital  organs,  it  varies  greatly  in  size ; 
in  children  it  is  rudimental.  At  the  age  of  puberty  it  grows  rapidly, 
but  does  not  attain  its  full  development  until  about  the  twenty-fifth 
year;  at  about  the  fiftieth  year  there  is  a  further  increase  of  size. 
On  an  average  the  normal  adult  prostate  is  about  one  and  a  half 
inches  wide  at  its  base  and  one  to  one  and  a  quarter  inches  long  and 

Fig.  223. 


f 


%l 


^ 


Vertical  section  of  pelvis  showing  the  bladder,  prostate  with  its  surrounding  plexus,  and  support- 
ing structures  of  the  perineum.    (Testut.) 

three-quarters  of  an  inch  thick.  It  weighs  about  five  drachms.  Its 
fibrous  muscular  capsule  is  intimately  connected  with  the  gland  sub- 
stance ;  its  outer  surface  can  be  stripped  from  the  prostatic  sheath  with 
comparative  ease.  The  stroma  is  composed  of  smooth  muscle  fibres 
and  connective-tissue  elements.  Bands  of  muscle  and  connective 
tissue  pass  from  the  capsule  into  the  substance  of  the  gland,  sepa- 

719 


720  GENITO-lTPtlNARY    DISEASES   AND   SYPHILIS. 

rating  the  lobules  and  giving  each  a  distinct  investment.  The  gland 
is  made  up  of  from  forty  to  sixty  of  these  lobules.  (Fig.  224.)  The 
relative  proportion  of  the  glandular  elements  to  the  stroma  varies 
greatly.  In  shape  it  somewhat  resembles  a  Spanish  chestnut,  though 
this  is  subject  to  many  variations.  It  may  be  thin  or  thick,  wide  or 
narrow,  short  or  long,  symmetrical  or  irregularly  developed.  To  the 
examining  finger  it  is  often  cordate,  presenting  a  central  notch  at  its  base. 
The  prostate  is  made  up  of  two  lateral  lobes  connected  by  an  isthmus, 
which,  from  its  thickness  and  from  the  fact  that  it  sometimes  forms  a 
distinct  projection,  has  been  called  the  third  lobe.  This  isthmus  lies 
just  below  the  vesical  orifice  of  the  urethra  and  above  and  behind  the 
ejaculatory  ducts,  discharging  its  secretion  into  that  portion  of  the  ure- 
thra which  lies  nearest  the  bladder.  The  prostate  is  placed  behind 
and  slightly  below  the  symphysis  pubis,  lying  between  the  posterior 
layer  of  the  triangular  ligament 
and  the  neck  of  the  bladder, 
which  is  surrounded  by  its  base. 
The  under  or  posterior  surface 
often  presents  a  central  furrow 
dividing  the  organ  into  two  dis- 
tinct lobes.  This  surface  is  in 
intimate  relation  with  the  rec- 
tum, from  which  it  is  separated 
by  the  thin  recto-vesical  fascia 
and    by    the    prostatic    sheath. 

The  latter  completely  invests  ''"ZlLZl^ZZtli'^IT^J^T^ 
the  gland,  forming  a  tough  con- 
nective-tissue covering  in  which  are  found  the  large  veins  of  the  pros- 
tatic plexus.  (Figs.  223,  224.)  Its  most  intimate  connection  with 
the  prostate  is  at  the  neck  of  the  bladder,  the  prostatic  veins  passing 
from  the  gland  at  this  point  to  join  the  fascial  plexus.  The  anterior 
surface  faces  towards  the  pubis,  from  which  it  is  separated  by  the 
plexus  of  Santorini  and  the  pubo-prostatic  ligaments.  The  lateral 
surfaces  are  in  relation  with  the  levator  ani  muscles,  to  which  they 
are  attached  by  fibro-muscular  fascia ;  the  vesico-prostatic  plexus  of 
veins  is  found  in  this  region.  The  base  of  the  prostate  embraces  the 
neck  of  the  bladder,  but  is  entirely  distinct  from  it. 

Between  the  lateral  lobes  and  above  the  commissure  or  posterior 
lobe  passes  the  prostatic  urethra  practically  surrounded  by  the  pros- 
tate, though  with  the  greater  bulk  of  this  organ  below  and  behind. 
The  utriculus,  a  structure  entirely  distinct  from  the  prostate,  lies 
in  this  mid-portion,  as  do  the  ejaculatory  ducts. 


INJURIES   AND   DISEASES   OF   THE    PROSTATE. 


721 


The  muscular  and  glandular  connections  between  the  normal 
prostatic  lobes  and  the  urethra  are  so  intimate  that  it  is  impossible 
to  remove  the  former  by  avulsion  or  blunt  dissection  without  extensive 

laceration  or  destruction  of  the 
Fig.  225.  former. 

More  than  three-fourths  of 
the  bulk  of  the  latter  is  made 
up  of  smooth  muscular  fibres. 
These  enclose  the  ducts  and 
acini  of  many  compound  race- 
mose glands.  In  these  acini, 
after  the  age  of  puberty,  are 
frequently  found  albuminoid 
sympexes.  The  greater  num- 
•  ber  of  the  excrelory  ducts  open 
upon  the  floor  of  the  prostatic 
sinus,  passing  somewhat  ob- 
liquely. Some  open  into  the 
sides  or  the  roof  of  the  canal, 
and  some  into  the  prostatic 
utricle.  These  glands  are  most 
numerous  in  the  posterior 
lower  portion  of  the  isthmus 
(middle  lobe). 

The  blood-supply  of  the 
prostate  is  derived  from  the  in- 
ternal pudic,  vesical,  and  hem- 
orrhoidal arteries.     The  veins 

Ejaculatory  ducts,  seminal  vesicles,  prostate,  mem-    are  particularly  numerOUS,  and 

SZ'are™"'..TMS«  "*■  """"^  °""'"'  f°™  ^  ™h  plexus  about  the 

sides,  base,  and  anterior  sur- 
face of  the  gland.  The  nerves  are  from  the  pudic  and  the  hypo- 
gastric plexus. 


CONTUSIONS   AND   WOUNDS   OF   THE    PROSTATE. 

Oontusion  of  the  prostate  is  probably  a  commoner  accident 
than  is  generally  supposed.  It  may  be  caused  by  kicks  or  blows  in 
the  posterior  perineum,  or  by  jars  such  as  may  be  received  in  horse- 
back or  bicycle  riding.  The  symptoms  are  those  of  acute  prostatic 
congestion, — i.e.,  deep-seated  pain,  tenesmus,  moderate  ardor  urinae, 
frequency  and  urgency  of  urination,  and  sometimes  a  sense  of  rectal 
fulness.     These  symptoms  subside  in  a  few  hours  or  a  few  days,  and, 


722  GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 

unless  there  has  been  a  preceding  latent  lesion,  are  unattended  by 
sequelae. 

The  pathological  alterations  which  take  place  from  comparatively 
slight  contusions  are  unknown,  since  they  never  result  fatally.  It  is 
possible  that  in  the  severer  forms  there  are  slight  multiple  paren- 
chymatous hemorrhages. 

Wounds  of  the  prostate,  except  those  inflicted  during  the 
course  of  a  surgical  operation,  are  of  minor  importance,  since  this 
gland  is  so  placed  that  the  vulnerating'body  which  reaches  it  almost 
necessarily  involves  other  and  more  important  structures.  Incision 
into  the  prostate  practised  during  the  course  of  surgical  operations  is 
unattended  by  danger,  unless  the  rich  plexus  of  veins  placed  at  the 
borders  of  this  gland  and  above  it  is  also  involved.  The  hemor- 
rhage then  may  be  serious  or  even  fatal.  From  the  prostate  itself 
bleeding  is  usually  moderate,  or,  if  severe,  is  readily  controlled  by 
packing. 

Should  infection  occur,  wounds  of  the  prostate  may  be  extremely 
dangerous,  since  septic  phlebitis  may  result,  rapidly  extending  along 
the  large,  freely  anastomosing  pelvic  veins,  and  causing  septicaemia  or 
pyaemia.  If  suppuration  takes  place  in  the  coats  of  the  veins,  they 
may  undergo  fatty  metamorphosis  and  break  down,  causing  serious 
hemorrhage. 

Prostatic  wounds  involving  the  urethra  are  subject  to  the  dangers 
of  internal  hemorrhage  and  urinary  infiltration.  The  blood  may  flow 
backward  into  the  bladder,  filling  it  with  a  thick,  clotted  mass,  which 
may  be  extremely  difficult  to  dislodge.  If  the  bleeding  is  profuse,  a 
hard,  globular  tumor  may  form  above  the  pubis. 

Prognosis. — Wounds  of  the  prostate,  particularly  those  which  do 
not  involve  the  urethra,  heal  promptly,  provided  they  are  kept  clean. 
When  the  urethra  is  opened  there  is  little  danger  of  urinary  extrava- 
sation if  abundant  provision  is  made  for  drainage.  These  wounds 
generaUy  heal  kindly,  and  are  seldom  followed  by  urinary  fistula  or 
interference  with  micturition ;  exceptionally  the  formation  of  a  pros- 
tatic cicatrix  interferes  with  the  action  of  the  vesical  sphincter  and 
causes  a  more  or  less  permanent  condition  of  incontinence. 

When  the  prostate  is  extensively  injured  and  the  capsular  invest- 
ment widely  torn,  dangerous  complications,  such  as  pelvic  cellulitis 
and  even  peritonitis,  may  follow.  The  lacerated  and  contused  wounds 
caused  by  forced  catheterization,  as  a  rule,  heal  kindly,  provided  the 
urine  is  not  infected.  If  this  fluid  is  septic  and  if  the  prostate  is 
already  infected,  abscess-formation,-  phlebitis,  and  infiltration,  ending 
in  septicaemia  and  death,  are  common. 


INJUEIES   AND   DISEASES   OF   THE   PEOSTATE.  723 

Treatment. — A  wound  of  the  prostate  not  involving  the  urethra 
should  be  cleansed  and  packed  with  sterile  gauze.  If  in  the  course 
of  twenty-four  hours  urination  becomes  difficult,  consequent  upon 
inflammatory  action,  a  permanent  catheter  should  be  worn  for  two  or 
three  days,  in  the  manner  described  when  treating  of  retention  of 
urine  from  enlarged  prostate.  If  the  prostatic  urethra  or  the  vesical 
neck  has  been  opened,  a  soft  catheter  should  be  passed  through  the 
urethra  into  the  bladder,  and  retained  there  for  several  days,  and  the 
perineal  wound  should  be  cleansed  and  packed.  If  it  is  impossible 
to  introduce  an  instrument  into  the  bladder,  median  perineal  ure- 
throtomy should  be  performed,  and  a  large,  soft  drainage-tube  should 
be  carried  through  this  opening  into  the  bladder  and  retained  there. 
If  there  is  bleeding,  the  catheter  en  chemise  should  be  introduced. 

When  the  wound  has  been  caused  by  forced  catheterization  and 
the  bladder  is  full  of  blood,  this  should  be  withdrawn  by  suction 
through  a  large  woven  or  metal  catheter,  or  through  the  evacuating- 
tube  used  in  htholapaxy,  if  this  instrument  can  be  introduced.  A 
full-sized  catheter  is  then  passed  into  the  bladder  and  is  retained  for 
several  days,  the  bladder  and  urethra  being  flushed  out  several  times 
daily  Avith  a  mild  antiseptic  solution. 

Should  symptoms  of  local  abscess  or  septic  infection  develop,  the 
prostate  should  be  opened  by  median  perineal  urethrotomy  and  thor- 
ough drainage  secured  through  this  opening.  If  after  wounding  the 
prostate  by  forced  catheterization  no  instrument  can  be  introduced 
into  the  bladder,  median  cystotomy  should  be  performed.  When 
hemorrhage  into  the  bladder  is  unattended  with  symptoms  of  dis- 
tention or  local  inflammation,  surgical  intervention  may  be  delayed, 
provided  the  urine  is  sterile  and  the  urethral  instrumentation  has  been 
practised  with  proper  antiseptic  precautions.  There  is,  however, 
always  a  risk  of  bacterial  infection :  hence  it  is  wiser  to  disintegrate 
the  clots  by  vesical  irrigation  and  at  the  same  time  keep  them  sterile 
by  using  antiseptic  solutions.  The  Thiersch  solution  will  usually 
suffice.      Urinary  antiseptics  should  at  the  same  time  be  given  by 

the  mouth. 

PROSTATITIS. 

Inflammation  of  the  prostate  may  be  acute  or  chronic ;  it  has  also 
been  classed  as  follicular, — i.e.,  confined  to  the  glands  and  periglan- 
dular tissue, — or  parenchymatous,  attacking  the  entire  organ. 

Causes. — The  immediate  cause  of  prostatitis  is  infection.  It  is 
true  that  inflammatory  reaction  invariably  follows  traumatism,  but  in 
the  absence  of  infection  this  undergoes  prompt  resolution.  Infection 
may  be  conveyed  along  the  urethra,  as  in  the  case  of  gonorrhoea ;  may 


724  GENITO-UEIXAET   DISEASES   AXD    SYPHILIS. 

be  either  hgematogenous  or  carried  by  the  urine,  as  in  prostatitis  which 
complicates  small-pox,  scarlet  fever,  typhus,  typhoid,  and  other  infec- 
tious diseases ;  or  may  reach  the  prostate  by  contiguity  of  structure, 
as  from  periprostatic  suppuration. 

Congestion  is  a  condition  which  strongly  predisposes  to  infection, 
and  which  is  apparently  essential  to  its  development.  Congestion 
may  be  due  to  traumatism,  as  from  instrumentation  or  jarring  of  the 
perineum,  excessive  venery,  constipation,  masturbation,  prolonged 
ungratified  sexual  excitement,  hemorrhoids,  irritating  applications, 
strongly  acid  or  alkaline  conditions  of  the  urine,  urethral  calculi, 
varicose  condition  of  the  prostatic  plexus,  over-distention  of  the 
bladder,  atheromatous  vessels,  chilling,  over-fatigue,  and  a  variety  of 
other  causes. 

The  common  causes  of  acute  prostatitis  are  the  backward  ex- 
tension of  gonorrhceal  urethritis  and  the  introduction  of  unclean  in- 
struments. The  bicycle  has  been  arraigned  as  a  frequent  exciter  of 
prostatic  inflammation.  Careful  investigation  convinces  us  that  bi- 
cycling does  not  predispose  to  diseases  of  the  prostate  or  otherwise 
injuriously  affect  the  gland,  especially  if  a  correct  attitude  be  main- 
tained. Every  surgeon  sees  cases  of  transitory  prostatic  irritation, 
nearly  always  due  to  the  use  of  a  saddle  which  presses  on  the  peri- 
neum. There  are  some  patients  with  sensitive  prostates  in  whom 
the  jarring  inseparable  from  riding  always  produces  an  aggravation 
of  symptoms.  These  are,  however,  few,  and  the  great  majority  of 
such  patients  experience  distinct  relief,  due  probably  in  the  main  to 
the  beneficial  effects  of  exercise,  yet  doubtless  in  part  to  direct  stimu- 
lation of  the  prostatic  circulation.  With  a  proper  seat  which  supports 
the  weight  on  the  tuberosities  of  the  ischium  when  the  patient  assumes 
the  correct  position,  we  believe  that  bicycle  riding  is  entirely  unob- 
jectionable so  far  as  the  prostate  is  concerned. 

Pathology. — Acute  prostatitis  is  characterized  by  marked  dilatation 
of  the  prostatic  plexus  of  veins  and  increased  vascularity  through  the 
entire  gland  ;  the  inflammation,  usually  beginning  in  the  mucous  mem- 
brane of  the  urethra,  extends  primarily  along  the  ducts  of  the  glands, 
and  secondarily,  when  these  have  become  obstructed,  forming  suppu- 
rating retention  cysts,  through  the  parenchyma  of  the  organ.  Ab- 
scesses may  appear  in  the  form  of  small  multiple  foci  or  as  large 
collections.  The  small  foci  represent  the  glands  transformed  to  sacs 
containing  mucus,  epithelium,  and  pus,  the  ducts  being  partially  or 
completely  obstructed.  As  the  inflammatory  secretion  increases  in 
quantity  the  glandular  capsule  may  rupture,  several  of  the  suppurating 
glands  becoming  confluent,  forming  large  accumulations.     The  ejacu- 


INJURIES   AND   DISEASES   OF   THE   PROSTATE.  725 

latory  ducts  are  always  involved  in  the  general  catarrhal  inflamma- 
tion, and  frequently  become  occluded  from  inflammatory  swelling 
and  epithelial  proliferation.  There  results  tension  in  the  seminal 
vesicles  and  the  ampullae  of  the  vas.  This  increases  congestion,  and 
thus  strongly  predisposes  to  further  extension  of  inflammation.  The 
prostatic  utricle  is  also  involved. 

Exceptionally  inflammation  extends  beyond  the  proper  capsule  of 
the  gland,  involving  the  tissues  lying  between  the  prostate  and  the 
rectum,  or  even  the  subperitoneal  connective  tissue.  This  peripros- 
tatitis may  be  due  to  rupture  of  the  pus  through  the  glandular  capsule, 
or  to  transmission  of  infection  through  the  medium  of  the  veins  and 
lymphatics.  The  infiltration  may  undergo  resolution  or  may  suppu- 
rate ;  suppuration  is  commonly  encountered  on  the  posterior  surface 
of  the  gland, — i.e.,  between  it  and  the  rectum.  It  may  form  an 
abscess  completely  surrounding  the  vasa  deferentia  and  the  seminal 
vesicles  without  exhibiting  any  tendency  to  rupture  into  them. 

From  this  brief  outline  of  the  pathology  of  the  inflammation  it  is 
evident  that  prostatitis  may  be  manifested  in  the  form  of  acute  hyper- 
Eemia  and  swelling,  usually  secondary  to  acute  catarrh  of  the  prostatic 
urethra ;  in  that  of  acute  folliculitis,  the  inflammation  involving  not 
only  the  prostatic  urethra,  but  also  the  prostatic  ducts  and  their  ac- 
companying glands,  and  transforming  them  into  sacs  filled  with  muco- 
pus  ;  in  that  of  a  large  destructive  abscess  due  to  fusion  of  the  smaller 
suppurating  foci ;  or  in  that  of  a  periprostatitis. 

Symptoms. — The  symptoms  of  prostatitis  vary  in  accordance  with 
the  form  and  severity  of  the  attack.  In  the  mildest  form,  character- 
ized by  acute  congestion,  there  are  feelings  of  weight  in  the  perineum, 
shooting  pains,  frequency  of  urination,  and  possibly  difficulty  in  start- 
ing the  stream  and  failure  to  experience  complete  relief  after  the 
bladder  is  apparently  empty,  pain  on  defecation,  and  tenderness  and 
enlargement.  When  inflammation  is  more  pronounced,  involving  the 
glands  and  their  ducts,  the  symptoms  already  noted  are  increased  in 
severity ;  there  is  often  the  sensation  as  though  a  foreign  body  were 
stuffed  in  the  rectum  ;  urination  is  frequent  and  urgent ;  a  small  stream 
is  passed  without  force,  and  often  intermittently,  aud  the  pain  is  severe. 
When  there  is  an  abscess-formation  in  or  about  the  gland  both  local 
and  general  symptoms  are  usually  pronounced.  There  is  constant 
pain  in  the  perineum,  aggravated  by  urination,  defecation,  or  motion 
of  any  kind  ;  sitting  down  or  crossing  the  legs  is  particularly  painful. 
There  is  a  constant,  urgent,  wearing  desire  to  urinate,  each  act  of  mic- 
turition voiding  a  small  forceless  stream.  Defecation  may  cause  great 
anguish.     Intermittent  urethral  discharge   is   characteristic.     Painful 


726  GENITO-URINAET   DISEASES   A^^D   SYPHILIS. 

erections  are  frequently  observed.  Rigors  or  chills,  followed  by  fever 
and  headache,  are  nearly  constant.  As  the  swelling  becomes  greater, 
urination  is  correspondingly  more  difficult,  until  finally  complete 
retention  may  result.  Hemorrhoids  often  develop,  caused  by  pelvic 
congestion,  or  possibly  by  the  constant  straining  efforts  at  urination 
which  prostatitis  often  occasions. 

Diagnosis. — The  diagnosis  of  acute  prostatitis  is  founded  on  the 
detection  by  rectal  palpation  of  a  hot,  tender  tumor  occupying  the 
position  of  the  prostate.  This,  in  conjunction  with  some  or  all  of 
the  above  symptoms,  and  especially  with  fever  and  with  pain  which 
is  especially  severe  during  defecation  and  at  the  end  of  urination,  is 
sufficient  to  establish  the  diagnosis. 

Prognosis. — The  prognosis  of  acute  prostatic  congestion,  in  the 
absence  of  infection,  is  extremely  favorable  ;  even  when  there  has  been 
infection,  provided  the  urethra  is  free  from  abnormal  narrowing  and 
there  is  no  local  or  general  cause  for  chronic  congestion,  recovery  is 
the  rule.  When  follicular  or  parenchymatous  suppuration  has  taken 
place,  the  prognosis  is  still  favorable,  although  there  is  always  danger 
of  septic  phlebitis.  The  glandular  abscesses  commonly  rupture  into 
the  urethra,  and  this  is  considered  a  favorable  termination.  So  far 
as  relief  of  immediate  symptoms  is  concerned,  this  is  undoubtedly 
correct;  but  when  the  abscesses  are  of  considerable  size  this  ter- 
mination is  less  favorable,  since  there  is  often  left  a  pouch  or  cavity 
which  will  continue  to  suppurate  indefinitely,  thus  maintaining  a  con- 
dition of  chronic  prostatitis,  and  in  which  the  urine  is  lodged,  de- 
posting  calculi,  which  ultimately  burrow  through  the  prostate  and 
cause  uro-purulent  infiltrations  of  the  surrounding  tissues  or  fistulae. 

Acute  parenchymatous  prostatitis  "characterized  by  rapid,  purulent 
breaking  down  of  the  entire  gland  may  result  fatally.  About  half 
these  cases  rupture  into  the  urethra. 

The  ordinary  directions  of  pointing  are  towards  the  urethra,  the 
rectum,  and  the  perineum.  The  pus  may  exceptionally  point  in  the 
inguinal  or  the  obturator  region ;  with  extreme  rarity  in  the  space  of 
Retzius,  in  the  peritoneal  cavity,  or  through  the  sciatic  foramen.  The 
opening  of  such  abscesses  into  the  recto-vesical  space  is  usually 
attended  with  the  formation  of  multiple  fistulse,  which  are  difficult  to 
cure.  Ransohoff  notes  that  of  sixty-seven  cases  twenty-one  opened 
into  both  the  rectum  and  the  urethra.  The  resultant  fistula  may  be 
beyond  relief. 

Segond  calls  attention  to  the  frequency  of  phlebitis  when  prostatic 
abscess  is  not  properly  drained.  About  forty  per  cent,  of  the  deaths 
are  due  to  this  cause.     He  reports  the  total  mortality  as  thirty-four  iv 


INJURIES   AND   DISEASES   OF   THE   PROSTATE.  727 

one  hundred  and  fourteen  cases.     This  is  extraordinary,  and  is  not  to 
be  accepted  as  the  usual  result. 

Treatment. — The  treatment  of  acute  prostatitis  consists  in  rest  in 
bed,  elevation  of  the  pelvis,  counter-irritation  or  local  depletion  by  the 
application  of  counter-irritants  or  leeches  to  the  perineum,  followed 
by  hot  fomentations,  hot  or  cold  rectal  douches,  or  ice-bags,  the 
use  of  opium  and  belladonna  suppositories,  the  internal  administra- 
tion of  urinary  antiseptics  and  bromides,  and  the  ingestion  of  large 

Fig.  226. 


Rectal  irrigator. 

quantities  of  water.  The  diet  should  consist  principally  of  milk.  Hot 
hip-baths  or  hot  general  baths  markedly  diminish  the  pain  and  tenes- 
mus, and  may  be  administered  several  tim.es  a  day,  the  patient  being 
subsequently  well  wrapped  up.  The  temperature  of  the  water  should 
be  at  least  105°  F.  In  the  beginning  of  the  attack  the  bowels  should 
be  freely  opened  by  salines.  After  this  there  should  be  no  effort  to 
procure  evacuation  for  several  days,  unless  there  is  reason  to  believe 
Ihat  the  rectum  is  filled  with  faecal  matter. 

The  most  troublesome  complication  is  retention  of  urine.  This 
is  overcome  by  the  introduction  of  a  soft  catheter.  When  this  is 
especially  difficult  or  painful  there  should  be  given  an  anaesthetic,  and 
an  instrument  having  once  been  introduced  should  be  left  in  place 
until  the  acute  symptoms  have  subsided. 

When  an  abscess  opens  into  the  urethra  spontaneously  or  as  the 
result  of  catheterization,  on  the  subsidence  of  acute  symptoms  every 
effort  should  be  made  to  cause  cicatrization  of  the  cavity.  If  this  is 
small,  spontaneous  healing  often  takes  place.  If  it  is  large,  suppu- 
ration continues,  kept  up  in  a  measure  by  the  urine,  which,  lying  in 
this  sac,  decomposes,  becomes  irritating,  and  often  deposits  calculi. 
The  tendency  of  this  ulcerating  sac  is  towards  gradual  extension, 
destroying  the  proper  capsule  of  the  prostate  and  causing  either 
extravasation  of  urine  or  periprostatic  abscess.  Obstinate  fistulas 
are  likely  to  form  as  the  ultimate  result  of  these  untreated  abscess- 
cavities. 

As  soon  as  the  acute  inflammatory  symptoms  have  subsided,  the 
suppurating  cavity  should  be  washed  out  twice  daily.  This  is  ac- 
complished as  follows.     By  means  of  a  finger  introduced  into  the 


728  GENITO-UEIN^AEY   DISEASES   AND   SYPHILIS. 

rectum  the  prostate  is  well  milked  and  the  abscess  emptied  of  its 
pus.  The  patient  is  then  directed  to  urinate,  and  the  urethra  and 
bladder  are  irrigated  with  a  mild  antiseptic  solution ;  boric  acid  or 
silver  nitrate  answers  well.  The  prostate  is  again  milked,  and  the 
patient  evacuates  that  portion  of  the  irrigating  fluid  which  has  entered 
the  bladder.     This  is  repeated  two  or  three  times  at  each  treatment. 

When  there  is  no  tendency  towards  the  spontaneous  evacuation 
of  the  abscess  through  the  urethra,  and  the  chills,  fever,  and  throb- 
bing pain  in  the  perineum  persist,  and  there  is  marked  increase  in  the 
swelling,  the  pus  should  be  evacuated  by  perineal  incision.  There 
should  be  no  hesitation  under  these  circumstances  in  performing 
the  operation,  since,  unless  the  abscess  ruptures  into  the  urethra^ 
it  is  liable  to  burst  through  the  capsule  of  the  gland,  infiltrate  the 
deep  pelvic  tissues,  and  not  infrequently  cause  pyaemia  and  death. 
The  operation  should  be  conducted  under  an  ansesthetic,  the  pros- 
tate being  exposed  by  a  semilunar  incision  in  front  of  the  rectum ,^ 
deepened  by  gradual  dissection.  The  focus  of  suppuration  may  then 
be  detected  by  the  exploring  needle.  When  the  tumor  is  obviously 
fluctuating  it  may  be  opened  by  a  long,  straight  bistoury  thrust  in  the 
middle  line  of  the  perineum  directly  in  front  of  the  rectum,  with  its 
back  towards  this  structure  and  guided  towards  the  abscess  by  a 
finger  introduced  through  the  anus.  After  opening  the  abscess  the 
cavity  should  be  flushed  out,  and  should  be  drained  either  by  gauze 
packing  or  by  tubes.  Urethral  fistula  occasionally  follows,  but  usu- 
ally closes  spontaneously. 

The  treatment  of  periprostatitis  and  periprostatic  abscess  is  the 
same  as  that  described  as  applicable  to  prostatitis.  The  pus  is  apt  to 
point  in  the  posterior  or  anal  perineum  and  to  invade  the  ischio-rectal 
space,  inasmuch  as  its  origin  is  behind  the  middle  perineal  fascia. 

Chronic  Prostatitis. — Following  an  acute  attack  of  prostatitis, 
or  secondary  to  posterior  urethritis  or  cystitis  without  a  history  of  an 
acute  attack,  the  prostate  may  become  chronically  inflamed.  The 
exciting  cause  is  infection,  the  predisposing  cause  congestion.  This, 
congestion  may  be  due  to  long-continued  ungratified  excitement, 
excessive  coitus,  masturbation,  hemorrhoids,  habitual  constipation, 
irritating  conditions  of  the  urine,  or  any  of  the  conditions  which  have 
already  been  mentioned  as  causing  pelvic  engorgement. 

The  pathology  of  the  affection  varies.  There  is  practically  always 
chronic  posterior  urethritis.  Associated  with  this  there  may  be  a 
catarrhal  condition  of  the  prostatic  glands,  attended  by  distinct  dilata- 
tion of  their  ducts  and  acini  and  marked  thickening  of  the  peri- 
glandular  tissue. 


INJUEIES   AND   DISEASES   OF   THE   PKOSTATE.  729 

There  may  be  one  or  many  abscesses  discharging  into  the  pros- 
tatic urethra  through  openings  insufficient  for  thorough  drainage. 
These  are  attended  by  general  engorgement,  and  ultimately  result  in 
the  development  of  fistulse,  or  in  cicatricial  deformity  or  atrophy  of 
the  prostate. 

Symptoms. — The  symptoms  of  chronic  prostatitis  may  be  slight  or 
severe.  Usually  there  is  increased  frequency  in  urination,  deep 
perineal  pain  which  radiates  to  the  rectum,  scrotum,  and  down 
the  thighs  and  is  made  worse  by  exertion,  slight  tenderness  in 
the  perineum,  thickening  and  sometimes  irregular  nodulation  of  the 
prostate.  After  urination  and  during  defecation  there  is  a  viscid 
milky  discharge,  containing  pus,  columnar  epitheKum,  and  amyloid 
prostatic  bodies.  The  pain  is  often  severe  at  the  end  of  urination, 
and  may  be  felt  either  in  the  deep  perineum  or  in  the  urethra,  a 
quarter  of  an  inch  behind  the  meatus.  It  is  burning  in  character. 
After  defecation  there  may  be  severe  burning  perineal  pain,  lasting  a 
few  minutes  or  for  several  hours.  There  are  frequent  intercurrent 
subacute  attacks  of  inflammation,  and  these  patients  very  commonly 
suffer  from  headaches  or  muscular  and  joint  pains  similar  to  those  due 
to  toxaemia  from  other  causes.  There  are  often  loss  of  sexual  desire, 
great  weakening  of  sexual  power,  and  frequent  pollutions.  On  rectal 
examination  the  prostate  may  be  unduly  sensitive  at  some  portion  of 
its  surface.  It  may  or  may  not  be  enlarged,  and  sometimes  is  dis- 
tinctly bossed  or  asymmetrical.  The  urme  passed  after  milking  this 
organ  contains  a  considerable  quantity  of  pus.  The  introduction  of 
an  instrument  into  the  prostatic  urethra  gives  more  pain  than  is  nor- 
mal, and  its  point  may  become  engaged  in  an  abscess-cavity.  The 
most  pronounced  symptom  in  these  cases  is  the  profound  alteration 
of  disposition.  These  patients  become  melancholic,  neurasthenic,  and 
invalided. 

Albarran  describes  a  proliferating  prostatitis  observed  in  both  the 
young  and  the  old,  characterized  by  the  symptoms  of  moderate  pros- 
tatic urinary  obstruction  and  the  presence  of  a  moderately  sized 
smooth,  or  slightly  nodular,  fairly  firm,  or  soft  prostate,  which  may  be 
sensitive  to  pressure. 

Prognosis. — In  chronic  prostatitis  the  lesions  of  which  are  mainly 
congestive,  with  follicular  catarrh  not  yet  having  developed  to  distinct 
abscess-formation,  there  is  a  tendency  towards  spontaneous  cure. 
Small  abscess-cavities  also  heal.  The  larger  sacs  show  no  such  ten- 
dency. They  are  rather  inclined  slowly  to  extend,  causing  peripros- 
tatic abscess  and  urethro-rectal  or  urethro-perineal  fistulae,  often 
complicated  by  calculi.     In  cases  characterized  by  symptoms  so  slight 


730  GENITO-UEINAKY   DISEASES   AND   SYPHILIS. 

as  to  excite  no  attention,  the  condition  may  remain  latent,  though 
slowly  progressive  for  years,  causing  ultimately  the  atrophied  prostate 
and  sclerosed  and  contracted  internal  vesical  sphincter  which  induce 
the  most  inveterate  forms  of  prostatism. 

Treatment. — On  beginning  the  treatment  of  chronic  prostatitis  the 
patient  should  be  informed  that  cure  is  slow  and  difficult  and  is  de- 
pendent upon  persistence  in  the  use  of  appropriate  therapeutic  meas- 
ures and  faithful  observance  of  the  laws  of  health.  General  direc- 
tions are  given  in  regard  to  diet,  exercise,  and  hours  of  sleep.  The 
urine  is  rendered  bland  and  slightly  antiseptic.  The  bowels  are  prop- 
erly regulated  by  enemata ;  erotic  excitement  is  avoided.  Ordinary 
sexual  intercourse  need  not  be  forbidden.  It  is  undoubtedly  true  that 
many  cases  of  chronic  prostatitis  would  be  cured  by  hygiene  alone  if 
it  included  regular  and  unemotional  sexual  gratification.  Unfortu- 
nately, the  majority  of  these  patients  are  young,  unmarried  adults, 
and,  even  if  the  question  of  morals  were  set  aside,  it  would  not  be 
possible  for  them  to  secure  sexual  relations  that  would  meet  their 
requirements.  Hip-baths  of  a  temperature  and  duration  governed 
by  the  sensations  of  the  patient  are  useful.  Rectal  lavage  with  hot 
or  cold  normal  saline  solution  should  be  used  daily.  The  use  of  the 
cold  jet  by  means  of  the  bidet  is  markedly  beneficial  in  many  cases. 

Massage  followed  by  urethral  irrigations,  as  described  in  the  treat- 
ment of  seminal  vesiculitis,  is  serviceable,  even  when  pus-collections 
are  not  present,  since  this  treatment  expresses  the  contents  of  the 
prostatic  glands  and  enables  the  cleansing,  slightly  stimulating  fluid 
used  for  irrigation  to  act  directly  upon  the  diseased  and  congested 
mucous  membrane.  In  a  chronic  prostatitis  kept  up  by  pus-cavities 
massage  is  of  special  importance. 

Local  applications  to  the  prostatic  urethra  are  generally  indicated 
for  the  relief  of  the  accompanying  posterior  urethritis.  These  are 
selected  and  applied  in  accordance  with  the  principles  already  laid 
down,  but  should  be  used  cautiously,  since  reactionary  swelling  may 
entirely  close  the  urethral  opening  of  a  chronic  abscess,  causing  re- 
tention of  pus,  extension  of  parenchymatous  inflammation,  and  septic 
absorption.  If  the  reaction  following  the  use  of  weak  instillations  is 
unusually  prolonged  and  severe  they  should  be  discontinued. 

The  treatment  of  urinary  retention,  with  its  painful  complications 
and  fatal  sequelae  dependent  on  sclerosis  of  the  internal  vesical 
sphincter  secondary  to  chronic  prostatitis,  requires  over-dilatation  or 
section  of  the  obstructing  ring.  Prostatectomy,  though  often  per- 
formed for  the  relief  of  this  condition,  is  not  indicated. 

Irritable   Prostate. — This   is   a   condition  characterized  by  re- 


INJUEIES   AND   DISEASES   OF   THE   PKOSTATE.  731 

peated  rather  sudden  and  acute  engorgements  of  the  prostate,  usually- 
dependent  upon  an  abnormal  condition  of  the  urine,  such  as  excessive 
acidity.  It  is  also  due  to  chilling  and  other  well-known  causes  of 
pelvic  congestion.  It  is  probable  that  it  does  not  attack  the  perfectly 
healthy  prostate.  It  has  been  so  often  observed  in  gouty  patients 
that  the  manifestations  of  this  form  of  irritability  are  in  them  called 
prostatic  gout. 

The  symptoms  are  those  of  the  first  stage  of  acute  prostatitis. 
There  develops  often  in  the  night  urgent,  frequent,  painful  urination. 
There  may  be  steady  or  shooting  pain  felt  in  the  perineum,  testicles, 
or  back.  On  rectal  examination  the  prostate  is  hypersensitive.  In 
gouty  patients  the  urine  is  extremely  acid  and  contains  an  excess  of 
mucus.  The  symptoms  attain  their  maximum  severity  during  the 
night,  and  the  prostate  remains  sensitive  for  some  time.  This  condi- 
tion of  irritability  may  be  the  first  step  in  the  development  of  cystitis 
or  calculus-formation. 

Diagnosis. — An  irritable  prostate  is  distinguished  from  an  inflamed 
gland  by  rectal  palpation  and  examination  of  the  urine.  Inflamma- 
tion is  always  accompanied  by  the  formation  of  pus  and  by  marked 
increase  in  the  size  of  the  prostate.  The  diagnosis  of  prostatic  gout 
depends  upon  the  constitutional  history  of  the  patient  and  examina- 
tion of  the  urine. 

Treatment. — The  irritable  prostate  is  amenable  to  treatment  directed 
to  the  relief  of  congestion.  Acid  or  irritating  conditions  of  the  urine 
should  be  remedied,  sexual  excess,  constipation,  and  the  well-recog- 
nized causes  of  pelvic  congestion  should  be  avoided,  and  the  prostatic 
circulation  should  be  strengthened  by  massage,  hot  rectal  injections, 
and  the  application  of  electricity.  In  general  the  treatment  applica- 
ble to  the  early  stages  of  acute  prostatitis  is  serviceable  for  the  relief 
of  acute  attacks.  The  medicinal  treatment  is  directed  to  the  equaliza- 
tion of  circulation  and  the  general  strengthening  of  the  patient.  Hyos- 
cyamine  and  ergotine  seem  to  have  some  value  by  their  direct  action 
on  local  circulation,  and  may  be  given  in  the  form  of  suppository. 

TUBERCULOSIS  OF  THE  PROSTATE. 
The  prostate  is  nearly  always  affected  in  genito-urinary  tubercu- 
losis, Krzywicki  noting  that  of  fifteen  cases  the  gland  showed  lesions 
in  fourteen.  Tuberculosis  may  be  primarily  in  the  prostate  or 
secondary  to  involvement  of  organs  either  adjacent  or  remote.  The 
proportion  of  cases  in  which  the  disease  is  primary  in  the  prostate  is 
not  known,  since  there  have  been  few  opportunities  offered  for  post- 
mortem  examination   until   tuberculosis   has   been  widely  diffused. 


732  GEXITO-UKIXAEY   DISEASES   AND   SYPHILIS. 

There  have,  however,  been  a  sufficient  number  to  prove  that  the  first 
manifestation  of  the  disease  may  appear  in  the  prostate  gland.  This 
gland  is  particularly  susceptible  to  infection  of  all  kinds,  Weigert 
having  proved  that  it  is  involved  in  the  majority  of  cases  of  pyaemia 
and  septicaemia.  Tubercle  bacilli  have  been  found  in  the  apparently 
healthy  prostate. 

Tubercular  prostatitis  is  commonest  in  the  prime  of  life.  It  is 
often  excited  by  posterior  urethritis ;  at  least  the  histories  of  many  of 
these  cases  show  that  tubercular  involvement  followed  gonorrhoea. 
It  is  evident  that  any  of  the  causes  of  prostatic  congestion  may  thus 
predispose  to  the  local  development  of  tuberculosis.  The  morbid 
anatomy  of  tubercular  prostatitis  is  that  characteristic  of  tubercular 
involvement  in  general, — i.e.,  exuberant  granulation,  central  degenera- 
tion, and  caseation.  The  tubercles  are  first  lodged  in  the  walls  of  the 
glandular  ducts,  extending  through  a  part  or  the  whole  of  the  gland, 
and  ultimately  either  undergoing  encapsulation  or  absorption,  a  rare 
termination,  or  softening  and  breaking  down,  forming  abscess-cavities. 

The  prostate  is  usually  enlarged  from  inflammatory  congestion ; 
abscess-formation  takes  place  slowly  but  surely.  Exceptionally  the 
lesions  develop  in  the  lower  outer  portion  of  the  gland  near  the 
rectum  ;  usually  they  are  observed  near  the  urethra.  In  this  case 
ulcers  are  formed  which  steadily  extend.  Abscesses  developing  in 
the  substance  of  the  gland,  though  occasionally  sclerosing  and  healing, 
commonly  enlarge  steadily,  opening  into  the  urethra,  the  rectum,  the 
perineum,  or  even  the  hypogastrium,  and  forming  multiple  fistulous 
tracts.     Tuberculosis  of  the  prostate  becomes  generalized  slowly. 

Symptoms. — The  symptoms  of  tubercular  infiltration  of  the  prostate 
are  practically  those  of  chronic  prostatitis,  and  are  probably  dependent 
upon  involvement,  or  at  least  secondary  congestion,  of  the  prostatic 
urethra.  The  patient  complains  of  frequent,  often  urgent,  urination, 
and  a  slight  continuous  or  intermittent,  glairy,  muco-purulent  dis- 
charge from  the  meatus.  Shreds  are  constant  in  the  urine  ;  there  may 
be  a  discharge  after  defecation  or  even  after  each  act  of  urination  ; 
sometimes  one  or  two  drops  of  blood  are  passed  at  the  end  of  uri- 
nation, and  attacks  of  acute  or  subacute  prostatitis  are  excited  by 
slight  and  apparently  insufficient  causes.  When  the  parenchymatous 
or  peripheral  portion  of  the  gland  is  involved  there  may  be  no  symp- 
toms for  a  long  time,  or  the  patient  may  note  slight  pain  during  defe- 
cation and  burning  pain  afterwards.  In  certain  cases  the  disease 
appears  to  begin  as  an  acute  parenchymatous  prostatitis.  On  the 
subsidence  of  the  early  inflammatory  symptoms  nodulation  may  be 
felt. 


Fig.  227. 


■■%^ 


Obstruction  toy  the  median  portion  of  the  prostate.     (Specimen  in  Museum  of  Philadelphia 

Hospital. ) 


Fig.  228, 


/   ' 


Separate  tumors  springing  from  the  lateral  lobes  of  the  prostate.    (Watson.) 


Fig.  229. 


Bilateral  hypertrophy  of  the  prostate.    A  thick  rigid  bar  at  the  neck  of  the  bladder 
unites  the  two  lateral  lobes.    (Watson.) 


Fig.  230. 


Hypertrophy  of  the  median  lobe  of  the  prostate.    (Watson.) 


Fig.  231. 


«X     '   ..■«.-C#*i 


■  ^ 


Hypertrophy  of  the  median  and  one  lateral  lobe  of  the  prostate,    a,  interureteral  bar.    (Watson.) 

FiCx.  232. 


Bladder  and  prostate  cut  through  longitudinally  in  the  median  line,  a,  lateral  lobe ;  6,  median 
lobe ;  c,  depression  behind  the  middle  lobe  called  the  bas-fond ;  d,  prostatic  urethra ;  e,  bladder- 
wall.    (Watson.) 


INJURIES   AND   DISEASES   OF   THE    PROSTATE.  733 

Diagnosis. — This  is  based  on  finding  the  tubercle  bacilH  in  the 
discharge  milked  from  the  prostate  and  subsequently  voided  with  the 
urine,  on  the  detection  of  thickening,  nodulation,  or  points  of  soften- 
ing on  rectal  examination,  and  on  the  discovery  of  tubercular  involve- 
ment of  the  epididymis  or  the  seminal  vesicles.  The  infiltration  some- 
times spreads  wide  of  the  prostate,  forming  a  large,  irregular,  diffuse 
mass  entirely  obscuring  the  outlines  of  the  prostate  and  vesicles. 

Prognosis. — This  is  extremely  grave.  Spontaneous  cure  by  a 
process  of  sclerosis,  though  possible,  is  rare. 

Treatment. — The  treatment  should  be  directed  towards  improving 
the  general  health  of  the  patient,  and  is  practically  that  appropriate  to 
pulmonary  consumption.  As  a  rule,  local  instrumentation  and 
applications  should  be  avoided,  with  the  exception  of  instillations 
of  mercuric  bichloride  (1  to  6000).  These  may  be  employed  as 
directed  in  the  treatment  of  tubercular  cystitis,  and  are  serviceable 
only  when  the  infiltration  begins  in  the  urethra  or  in  the  ducts  of  the 
glands.  Silver  nitrate  causes  pronounced  and  prolonged  exacerbation 
of  suffering. 

In  conducting  local  treatment  it  must  be  remembered  that  tuber- 
cular infiltration  especially  predisposes  the  involved  portions  of  the 
prostate,  and  the  bladder,  which  also  often  shows  tubercular  lesions, 
to  the  invasion  of  the  ordinary  pus  micro-organisms :  hence  special 
antiseptic  precautions  should  be  taken  in  the  use  of  instruments. 

Direct  operative  treatment  is  indicated  when  the  general  condition 
of  the  patient  is  fairly  satisfactory  and  it  is  evident  that  the  disease  is 
steadily  progressing. 

Incision  is  indicated  when  an  abscess  develops  which  threatens  to 
form  a  fistula.  The  prostate  should  be  fully  exposed  by  the  semilunar 
incision  in  front  of  the  anus,  and  all  the  diseased  tissue  should  be 
removed  by  the  curette,  the  urethra  not  being  opened  if  it  is  possible 
to  avoid  this.  The  wound  is  treated  by  packing  with  iodoform  gauze. 
Abscesses  opening  into  the  urethra  are  kept  clean  by  irrigation. 
Retention  of  urine  is  relieved  by  continuous  catheterization  or  supra- 
pubic drainage. 

ENLARGEMENT   OF   THE   PROSTATE. 

Enlargement  or  hypertrophy  of  the  prostate  consists  in  an  over- 
growth of  the  normal  cellular  constituents  of  the  gland  taking  place 
in  the  lobes  or  the  isthmus  or  affecting  the  entire  organ.  At  the  be- 
ginning of  the  overgrowth  the  change  in  form  is  best  expressed  by 
what  Thompson  calls  an  unnatural  tendency  to  rotundity.  The  gland 
is  increased  in  thickness  rather  than  in  other  dimensions,  the  lateral 


734  GENITO-UEIlSrAEY   DISEASES   AND    SYPHILIS. 

lobes  encroaching  to  some  extent  upon  the  urethral  lumen.  If  the 
enlargement  is  progressive  it  is  likely  to  be  somewhat  irregular,  certain 
portions  of  the  gland  increasing  more  rapidly  than  others.  The  poste- 
rior isthmus,  the  so-called  median  lobe,  is  frequently  affected,  though 
the  bulk  of  the  growth  may  occupy  one  lateral  lobe,  or  bosses  may 
project  from  both  lobes  and  the  isthmus,  producing  great  distortion 
of  the  urethra,  diverting  it  from  its  normal  course,  and  sometimes 
considerably  lengthening  it.  (Figs.  232,  233.)  The  growth  is  most 
rapid  in  the  lower  posterior  isthmus  (median  lobe). 

In  its  overgrowth  the  prostate  may  be  greatly  enlarged  and  soft, 
indicating  a  preponderance  of  glandular  overgrowth ;  may  be  moder- 
ately enlarged,  or  even  small  and  hard,  suggesting  an  excessive  stromal 
proliferation,  particularly  of  the  connective-tissue  elements,  or  may 
represent  a  combination  of  these  two  types. 

The  large,  soft  nodules  are  readily  shelled  out  from  the  thickened 
capsule.  In  the  atrophic  forms  of  enlargement  the  capsule  is  densely 
adherent,  and  in  total  operations  must  be  stripped  from  the  fascial 
sheath. 

The  enlargement  may  be  general  and  symmetrical,  or  may  involve 
chiefly  the  right,  left,  or  median  lobe,  or  combinations  of  two  of  them. 

The  direction  of  growth  may  be  towards  the  bladder,  the  urethra, 
or  the  rectum.  The  overgrowth  may  be  limited  to  the  posterior 
isthmus,  which  may  form  a  projecting  intra-urethral  or  intracystic 
sessile  or  pedunculated  mass  (bar  at  the  neck  of  the  bladder)  (Figs. 
227,  230),  which  may  seriously  interfere  with  urination.  The  anterior 
commissure  (isthmus)  has  only  exceptionally  been  involved.  Hyper- 
trophy commonly  involves  the  three  lobes  and  is  progressive,  though 
somewhat  unevenly,  in  all.  Its  projection  upward  and  backward  is 
incident  to  lessened  resistance,  the  fascial  investment  limiting  its  down- 
ward and  forward  growth. 

As  to  the  amount  of  overgrowth,  this  varies  within  wide  limits. 
The  tumor  may  be  little  larger  than  normal,  or  may  reach  the  size  of 
an  orange  or  even  of  a  cocoanut. 

Far  more  important  than  the  position  and  size  of  the  growth  are 
the  alterations  it  causes  in  the  length,  direction,  and  calibre  of  the 
prostatic  urethra,  and  in  the  patulousness  of  the  neck  of  the  bladder. 
In  consequence  of  the  increase  in  thickness  and  the  upward  and  back- 
ward growth  of  the  lateral  lobes,  the  transverse  diameter  of  the 
urethra  is  lessened,  and  its  length  is  increased  in  some  cases  by  as 
much  as  three  and  one-half  inches.  If  the  growth  is  asymmetrical, 
the  canal  will  be  deflected  from  its  regular  curve.  Thus,  if  the  median 
portion  enlarges  more  rapidly  than  the  lateral  lobes  the  floor  of  the 


INJUEIES   AND   DISEASES   OF   THE   PROSTATE.  735 

urethra  is  lifted  up,  forming  an  abrupt  projection,  which  effectually 
prevents  the  introduction  of  the  ordinary  silver  catheter.  When  one 
lateral  lobe  is  developed  more  than  another  there  is  lateral  deviation, 
with  the  concavity  of  the  curve  towards  the  most  affected  side.  Over- 
growth of  the  median  commissure  may  result  in  the  formation  of  a 
pyriform  tumor,  which  projects  at  the  vesical  end  of  the  urethra,  leav- 
ing a  passage  on  either  side. 

The  posterior  commissure  growing  backward  into  the  bladder 
may  become  pedicled,  forming  a  true  valve ;  commonly  it  is  sessile. 
The  lateral  lobes  may  project  backward  about  the  vesical  neck  in  the 
form  of  multiple  tumors,  which  encroach  upon  the  vesical  cavity  and 
•lift  the  neck  above  the  level  of  the  base,  forming  two  vesical  pouches, 
one  above  and  in  front,  behind  the  pubis,  the  other  below  the  prostate 
in  the  bas-fond.  The  lower  pouch  is  usually  caused  by  overgrowth 
of  the  posterior  commissure  (median  lobe).  (Fig.  232.)  Between  the 
ureters  there  is  normally  an  interureteral  bar,  made  up  of  muscular 
fibres,  not  distinguishable,  except  by  dissection,  in  the  normal  bladder; 
this  bar  becomes  greatly  hypertrophied  in  enlarged  prostate  because 
of  the  frequent  straining  efforts  to  expel  urine  from  the  region  in 
which  it  is  apt  to  accumulate  and  cause  irritation. 

Pathology. — The  chief  characteristic  of  a  microscopic  section  from 
an  enlarged  prostate  is  glandular  hyperplasia.  The  ducts  and  acini  may 
be  dilated,  and  the  latter  coalescent,  and  lined  with  either  a  single  layer 
of  epithelium  or  so  fdled  with  cells  as  to  simulate  cancer.  Malignant 
degeneration  of  an  enlarged  prostate  has  been  frequently  observed 
by  Albarran,  and  when  the  epithelial  cells  are  observed  breaking 
through  the  basement  membrane  and  infiltrating  the  stroma  the 
diagnosis  of  beginning  cancer  can  be  made  with  some  certainty.  The 
epithelial  lining  of  both  the  ducts  and  acini  may  entirely  disappear, 
and  the  latter  may  be  represented  by  fibrous  lissue.  The  acini  are 
at  times  distended  with  inflammatory  products,  forming  multiple 
chronic  abscesses  in  the  substance  of  the  gland,  or  they  may  be  filled 
with  their  own  secretion,  which  exhibits  a  tendency  to  form  con- 
cretions. 

The  stromal  outgrowth  is  usually  made  up  of  an  increase  in  con- 
nective tissue,  the  smooth  muscular  fibres  exhibiting  a  tendency  to 
disappear,  though  true  myomatous  overgrowths  have  been  observed. 
There  are  scattered  through  it  areas  of  round  cell  infiltrate,  suggesting 
inflammation.  Section  of  an  enlarged  prostate  shows  upon  examina- 
tion a  series  of  projecting  spheroidal  lobulations  which  can  be  readily 
shelled  out  from  the  surrounding  tissues.  These  fibro-adenomatous 
masses  vary  from  the  size  of  a  pea  to  that  of  an  e^^,  and  represent 


736  GEXITO-UEIXAET   DISEASES   AND   SYPHIEI3. 

overgrown  Iqbules,  each  with  its  fibroid  or  fibro-muscular  investment 
and  glandular  centre. 

There  is  no  evidence  to  show  that  the  small  hard  prostate  is  a 
secondary  stage  of  the  large  soft  enlargement,  nor  that  the  type  char- 
acterized by  gland  hyperplasia  becomes  ultimately  converted  into  the 
form  w^hieh  exhibits  predominance  of  fibroid  tissue.  Each  form  seems 
to  begin  and  to  progress  independently.  The  pathological  changes  in 
the  bladder,  ureters,  and  kidneys,  incident  to  prostatic  outgrowth,  are 
those  incident  to  obstruction  in  old  men,  whose  bladders  are  under- 
going muscular  degeneration  and  have  already  been  described.  (See 
page  297.)  They  lead  inevitably  to  renal  insufficiency  and  uraemia, 
usually  heralded  by  a  sudden  gastro-intestinal  breakdown. 

Fig.  233. 


Distorted  urethra  from  enlareed  prostate.     (Murphy.) 

Etiology. — The  evidence  derived  from  the  more  recent  pathological 
studies  of  the  prostate  gland  points  somewhat  to  the  dependence  of  this 
condition  upon  chronic  inflammation  which  remains  latent,  in  so  far  as 
symptoms  are  concerned,  until  the  organ  reaches  large  dimensions  or  so 
distorts  the  urethra  as  to  cause  urinary  obstruction.  Irregularly  dis- 
tributed through  the  stroma  there  is  practically  always  a  round  cell  in- 
filtration most  marked  about  the  urethra  ;  in  the  stroma  surrounding 
the  ducts  and  acini  are  seen  either  fibroblasts  or  true  cicatrices.  Press- 
ure upon  this  infiltrate  by  obstructing  the  ducts  may  cause  their  gland- 
ular overgrowth  or  possibly  true  cyst  formations.  If  this  is  uniform, 
the  tissue  is  so  widely  diffused  through  the  prostate  that  the  acini  them- 
selves are  compressed  and  atrophy  will  result.    Usually  the  connective- 


INJFKIES   A>TD   DISEASES   OF   THE   PROSTATE. 


737 


tissue  cells  remain  of  the  embryonal  type  and  by  their  proliferation 
produce  enormous  tumors  made  up  of  connective  tissue.  Should  they 
undergo  cicatricial  contracture,  the  prostate  may  become  smaller  than 
normal,  and  this  condition  is  at  times  noted. 

Against  the  inflammatory  theory  of  prostatic  enlargement  it  may  be 
said  that  it  is  a  disease  of  declining  years,  having  been  rarely  observed 


Fig.  234. 


Fig.  235. 


Prostatic  obstruction.  Effect  on  blad- 
der and  kidneys.  ( Specimen  in  Museum 
of  Philadelphia  Hospital.) 


Prostatic  obstruction  with  hypertrophy  of  the 
bladder- wall  and  contraction  of  its  cavity.  (Specimen 
ill  Museum  of  Philadelphia  Hospital. ) 


before  the  age  of  fifty,  that  no  relation  can  be  traced  between  its  de- 
velopment and  a  history  of  preceding  acute  or  chronic  prostatitis,  that 
thirty-three  per  cent,  of  men  above  sixty  show  some  evidence  of  en- 
largement, and  that  practically  the  prostates  of  all  men  past  middle 
age  are  shown  on  microscopical  study  to  be  subject  to  the  same 
adenomatous  change  which  in  its  more  complete  development  is  called 
prostatic  hypertrophy. 


738  GENITO-UEIKAEY   DISEASES   AISTD   SYPHILIS. 

As  a  working  hypothesis  the  following  explanation  has  been  sug- 
gested (White) : 

The  function  of  the  testis,  like  that  of  the  ovary,  is  twofold, — the 
reproduction  of  the  species  and  the  development  and  preservation  of 
the  secondary  sexual  characteristics  of  the  individual.  The  need  for 
the  exercise  of  the  latter  function  ceases  when  full  adult  life  is  reached, 
but  it  is  possible  that  the  activity  of  the  testis  and  that  of  the  ovary  in 
this  respect  do  not  disappear  coincidently,  and  that  hypertrophies  in 
closely  allied  organs  like  the  prostate  and  the  uterus  are  the  result  of 
this  misdirected  energy.  This  hypothesis  would  increase  the  analogy 
between  the  fibromyomata  of  the  uterus  and  the  adenofibromata 
of  the  prostate,  which,  from  a  clinical  stand-point,  is  already  very 
striking,  and  is  further  strengthened  by  the  almost  identical  result  of 
castration  in  the  two  conditions. 

The  dependence  of  prostatic  enlargement  upon  general  atheroma 
remains  to  be  proved,  though  it  is  undoubtedly  true  that  these  two 
elements  are  often  associated  and  are  common  at  the  same  period  of 
hfe.  There  is  a  variety  of  overgrowth  in  which  the  prostate  becomes 
excessively  hard,  showing  little  alteration  in  shape  or  size,  but  giving 
rise  to  marked  obstruction  may  have  for  its  cause  a  general  sclerosis, 
though  it  is  more  probably  due  to  fibroid  degeneration  following 
chronic  inflammation.  Richardson  states  that  "  the  change  in  the 
prostate  appears  to  be  as  common  as  gray  hairs."  "  It  is  not  a  disease 
process." 

Symptoms. — The  symptoms  of  enlarged  prostate  are  mainly  de- 
pendent upon  interference  with  the  function  of  micturition  :  hence 
it  is  possible,  when  the  overgrowth  occupies  such  a  position  in  the 
gland  as  not  to  interfere  with  the  calibre,  dilatability,  or  direction 
of  the  urethra,  that  it  may  attain  large  proportions  before  any 
symptoms  are  excited.  As  soon  as  the  tumor  grows  in  such  a 
direction  or  reaches  such  size  that  the  urethral  calibre  is  distinctly 
encroached  upon,  the  patient  will  notice  that — (1)  Micturition  is 
unduly  frequent,  this  frequency  being  most  marked  during  the  night 
or  in  the  early  morning.  (2)  There  is  some  delay  in  starting  the 
stream,  and  this  does  not  flow  with  its  wonted  force,  falling  almost 
directly  from  the  penis  without  the  customary  parabolic  curve.  (3) 
There  is  a  tendency  to  dribble  on  the  completion  of  the  act  of  mic- 
turition. . 

Provided  infection  does  not  take  place,  with  the  development  of 
posterior  urethritis  and  cystitis,  these  may  be  the  only  symptoms  of 
which  the  patient  complains  until  the  distention  of  the  bladder  reaches 
such  a  point  that  incontinence  of  retention  develops.     As  a  rule,  long 


INJUMES   AND   DISEASES   OF   THE   PROSTATE.  739 

before  this  there  is  set  up  a  certain  amount  of  urethritis  and  cystitis. 
There  are  then  added  to  the  obstructive  symptoms— i.e.,  frequency, 
most  marked  at  night,  slowness  in  starting  the  stream,  loss  of  force, 
and  dribbling — the  symptoms  of  inflammation,  pain,  and  suppuration. 
The  pain  may  be  manifest  in  the  form  of  a  sensation  of  weight,  of  a 
weak  and  tired  feeling,  of  an  ache  which  may  be  steady  or  intermit- 
tent, or  sharp  or  dull  pains  may  be  felt  in  the  perineum,  scrotum, 
hypogastric  region,  groins,  inner  surfaces  of  the  thighs,  back,  and 
testicles.  Later  there  are  pains  above  the  pubis  and  sharp,  shooting 
pains  in  the  urethra  behind  the  glans  penis.  Urination  becomes 
excessively  frequent  and  painful,  is  attended  with  violent  straining, 
and  is  suddenly  and  frequently  interrupted  ;  the  stream  is  small  and 
broken.  The  urine  becomes  alkaline  and  offensive,  is  turbid  with  pus 
and  mucus,  and  there  is  often  a  muco-purulent  urethral  discharge. 

Frequency  of  urination  in  cases  with  non-infected  bladders  is  due 
to  residual  urine.  This  occupies  the  space  that  should  be  taken  up 
by  fresh  secretion  from  the  kidneys,  and  hence  causes  the  bladder  to 
become  distended  sooner  than  would  be  the  case  normally.  The 
amount  of  residual  urine  is  proportionate  to  the  degree  of  obstruction, 
and  as  it  increases  in  quantity  it  causes  gradual  distention  of  the 
bladder-walls,  with  atrophy  and  degeneration  of  the  vesical  muscles, 
nearly  always  preceded  by  hypertrophy  incident  to  the  efforts  made 
to  overcome  resistance. 

The  frequency  of  urination  is  in  the  absence  of  inflammation  pro- 
portionate to  the  degree  of  vesical  distention.  This  symptom  is  es- 
pecially distressing  because  it  is  most  pronounced  during  the  night, 
in  advanced  cases  compelling  the  patient  to  rise  every  half-hour. 
Nocturnal  frequency  has  been  ascribed  to  the  more  irritating  nature 
of  the  urine  secreted  at  night  and  to  the  increase  in  the  quantity 
secreted.  This  may  be  true  in  part,  but  it  may  be  doubted  if  urination 
is  really  much  more  frequent  in  the  night  than  in  the  day.  All  night 
disturbances  make  a  much  deeper  impression  than  those  by  day,  and 
anxiety  exaggerates  a  few  disturbances  into  a  constant  series.  It 
must  be  borne  in  mind  that  when  the  patient  micturates  once  during 
the  night  it  is  significant,  and  the  gravity  of  this  significance  increases 
with  the  frequency  of  the  act. 

Residual  urine,  and  hence  frequent  urination,  are  more  marked 
and  earlier  symptoms  when  there  is  hypertrophy  projecting  back- 
ward from  the  median  portion  of  the  prostate.  Owing  to  the  altered 
relation  produced  by  the  overgrowth  of  the  neck  of  the  bladder,  a 
pouch  is  formed  about  the  outlet.  In  this  a  certain  amount  of  urine 
is  contained  which  the  atrophied  and  degenerated  bladder-walls  are 


740  GENITO-UEIISrAEY   DISEASES   AIS^D   SYPHILIS. 

unable  to  expel.  This  pouch  increases  in  size  as  the  bladder  becomes 
distended,  until  a  condition  of  chronic  tension  is  reached,  character- 
ized by  an  incontinence  which  in  prostatics  is  nearly  always  indicative 
of  retention. 

Loss  of  force  in  the  stream  is  due  in  part  to  atony  and  degen- 
eration of  the  bladder-muscles,  in  part  to  the  urethral  obstruction. 
Slowness  in  starting  micturition  and  dribbling  on  the  completion  of 
the  act  are  caused  partly  by  the  atony,  partly  by  reflex  spasm  of  the 
compressor  urethrse  muscle. 

Very  exceptionally  complete  retention  of  urine  is  an  early  symp- 
tom of  hypertrophy.  It  is  then  an  expression  of  acute  congestion 
incident  to  excess,  exposure  to  cold,  etc.  In  the  later  stage  of  the 
affection  it  is  due  to  permanent  overgrowth.  As  a  result  of  vesical 
and  renal  retention  there  is  always  polyuria,  the  urine  being  of  low 
specific  gravity.  This  hypersecretion  of  urine  is  one  cause  of 
frequency,  and  this  fact  should  be  remembered  in  estimating  the 
bladder-capacity  and  the  significance  of  frequent  urination. 

As  the  disease  progresses,  in  consequence  of  severe  straining, 
hemorrhoids,  rectal  prolapse,  or  abdominal  hernia  may  develop. 
Ultimately,  if  the  obstruction  is  untreated,  there  will  be  dilatation  of 
the  ureters  and  kidney  pelves,  and  in  infected  cases  the  development 
of  pyelonephritis  and  ureemic  poisoning. 

Exceptionally  there  is  bleeding.  This  may  be  severe  and  sponta- 
neous, in  w^hich  case  there  is  usually  relief  of  symptoms.  It  is  com- 
monly due  to  instrumentation.  The  presence  of  albumen  in  the  urine 
does  not  necessarily  indicate  involvement  of  the  kidneys,  since  this 
may  be  due  to  the  constant  straining  and  frequent  micturition.  Cal- 
culus not  infrequently  develops. 

It  is  evident  that  the  symptoms  of  enlarged  prostate  are  those  of 
obstruction  to  the  passage  of  urine,  to  which  are  ordinarily  added 
symptoms  of  inflammation.  The  obstructive  symptoms  are  compara- 
tively painless,  and  are  slowly  progressive  ;  they  ultimately  bring  about 
changes  in  the  upper  urinary  tract,  which  lead  to  gastro-intestinal 
disturbance,  uraemia,  and  death.  Inflammation  converts  this  slow, 
painless  disease  into  one  that  is  extremely  painful,  is  often  rapid  in 
its  course,  and  is  immediately  threatening  to  life.  From  this  con- 
sideration the  importance  of  strict  cleanliness  in  dealing  with  cases 
of  enlarged  prostate  is  evident. 

Diagnosis. — In  the  presence  of  the  symptoms  of  prostatic  ob- 
struction in  a  man  over  fifty-five  years  of  age, — i.e.,  a  full-sized 
but  feeble  stream  started  with  difficulty,  frequent  urination,  most 
marked  at  night,  and  a  feeling  as  though  the  bladder  were  not  com- 


IISTJIJEIES   AND   DISEASES   OF   THE   PKOSTATE.  741 

pletely  emptied, — a  positive  diagnosis  may  be  made  by  direct  ex- 
amination. 

The  first  step  in  this  direction  consists  in  tlie  introduction  of  a 
finger  into  the  rectum. 

The  patient  standing  with  his  legs  apart  and  leaning  forward,  his 
hands  upon  a  table  or  chair,  the  index-fmger  protected  by  a  cot  is 
introduced  through  the  sphincter,  and  an  effort  is  made  to  feel  the 
apex  of  the  prostate.  As  the  finger  is  entered  more  deeply  the  lateral 
outlines  of  the  gland  are  explored,  and  its  density,  the  irregulari- 
ties of  its  surface,  finally  the  height  to  which  it  reaches,  are  noted, 
the  finger  being  carried  on  until  the  soft  bladder  can  be  felt  above  the 
upper  border  of  the  prostate.  In  these  subjects  bimanual  palpation 
is  distinctly  serviceable.  It  will  be  remembered  that  the  normal  pros- 
tate is  about  the  size  of  a  horse-chestnut,  is  often  cordate  in  shape, 
with  the  base  upward  towards  the  bladder,  is  not  very  sensitive  to 
pressure,  and  can  be  clearly  outlined  by  rectal  palpation.  Above  it 
the  bladder-wall  can  be  felt. 

The  next  step  in  direct  examination  consists  in  the  introduction  of 
urethral  instruments.  This  will  enable  the  surgeon  to  determine  the 
extent  to  which  the  prostatic  portion  of  the  canal  hasbeendengthened, 
the  thickness  of  the  gland,  the  presence  of  lateral  deviations,  and  the 
general  nature  of  an  obstruction  placed  at  the  neck  of  the  bladder. 

For  the  purpose  of  determining  the  extent  to  which  the  urethra  is 
lengthened,  a  soft  elbowed  catheter  is  employed.  Urethral  length 
varies  so  greatly  in  individuals  that  it  is  impossible  to  establish  a 
standard  which  will  apply  to  each  case.  Perhaps,  as  a  rule,  it  is  safe 
to  conclude  that  if  the  catheter  has  to  be  passed  more  than  eight  and 
one-half  inches  to  evacuate  the  urine  from  a  bladder  containing  three 
or  four  ounces,  the  prostate  is  enlarged.  A  more  accurate  way  of 
arriving  at  the  length  of  the  prostatic  urethra  is  to  determine  the 
length  of  the  anterior  urethra  by  passing  an  acorn-headed  bougie  to 
the  anterior  layer  of  the  triangular  ligament.  A  catheter  is  then  intro- 
duced into  the  bladder  containing  but  a  few  ounces,  and  when  urine 
begins  to  flow  the  point  on  its  shaft  corresponding  to  the  position  of 
the  meatus  is  marked.  When  the  catheter  is  withdrawn,  measure- 
ments are  taken  from  this  point  to  the  end  of  the  eye.  Subtracting 
the  anterior  urethral  length  from  the  total  length,  the  remainder 
represents  the  length  of  the  prostatic  and  membranous  portions  of 
the  canal ;  three-quarters  of  an  inch  can  be  allowed  for  the  mem- 
branous urethra.  Should  the  prostatic  urethra  be  found  over  one 
and  three-quarter  inches  long,  the  diagnosis  of  enlargement  of  the 
prostate  is  reasonably  assured. 


742  GEJSriTO-UEINARY   DISEASES   A^D   SYPHILIS. 

Metal  instruments  are  employed  to  determine  the  presence  of 
lateral  deviations  of  the  prostatic  urethra,  the  thickness  of  the 
enlarged  gland,  and  the  seat  and  projection  of  growths  about  the  neck 
of  the  bladder.  They  should  never  be  grasped  tightly  when  they  are 
introduced.  A  stone  searcher  when  it  can  be  introduced  without 
the  use  of  undue  force  is  best  adapted  to  the  purpose.  Pressure 
should  be  gentle,  and  so  directed  that  the  instrument  may  follow  any 
slight  irregularities  in  the  direction  of  the  prostatic  urethra.  It  will 
often  happen  that  before  the  instrument  can  be  made  to  enter  the 
bladder  the  handle  must  be  considerably  lateralized,  showing  devia- 
tion of  the  urethra  to  one  side,  or  when  the  middle  portion  of  the 
prostate  is  enlarged  and  projects  upward  the  handle  may  have  to  be 
depressed  much  more  than  is  usually  the  case.  When  the  instrument 
has  entered  the  bladder,  palpation  against  its  shaft  through  the  rectum 
may  give  an  approximate  idea  of  the  antero- posterior  diameter  of  the 
gland.  The  beak  of  the  instrument  is  then  turned  in  all  directions, 
and  a  careful  exploration  is  made  for  stone,  since  this  is  a  fre- 
quent complication  of  prostatic  enlargement.  After  exploration  of 
the  bladder  is  completed  the  instrument  is  withdrawn  until  the  beak 
lies  just  within  the  internal  vesical  sphincter.  Then,  by  turning  it 
from  side  to  side,  not  only  can  the  base  of  the  bladder  be  explored, 
but  polypoid  tumors,  which  sometimes  project  about  the  neck  of  the 
bladder,  can  be  distinctly  felt.  In  case  of  a  healthy  bladder  and  pros- 
tate, the  rotation  of  this  sound  when  its  beak  is  still  within  the  neck 
of  the  bladder  is  unattended  with  resistance.  If  there  is  marked 
hypertrophy,  and  particularly  if  the  middle  portion  of  the  prostate  is 
affected,  jutting  back  into  the  bladder,  the  beak  of  the  instrument 
cannot  be  rotated  in  this  way,  but  will  encounter  a  resistance  froni 
which  it  can  be  freed  only  by  greatly  depressing  the  handle.  For  the 
purpose  of  determining  by  instrumentation  which  lateral  lobe  is  en- 
larged, Mercier,  after  having  explored  the  bladder,  withdraws  the 
instrument,  keeping  its  shaft  as  nearly  horizontal  as  possible  as  it 
traverses  the  prostatic  urethra.  The  shaft  of  the  bougie  will  be 
deflected  to  the  side  of  the  greatest  enlargement ;  in  cases  of  sym- 
metrical enlargement  there  will  be  no  deflection. 

The  patency  of  the  urethra  and  the  encroachments  upon  its  cah- 
bre  by  prostatic  outgrowths  are  best  ascertained  by  introducing  full 
calibre  solid  steel  instruments,  or  silver  or  soft  English  catheters.  If 
these  instruments  are  arrested  at  a  point  more  than  seven  inches  from 
the  meatus,  the  obstruction  is  in  the  prostatic  urethra.  If  an  instrument 
with  a  prostatic  curve  is  arrested  at  the  same  point,  but  on  continued 
pressure  passes  on  into  the  bladder,  often  with  a  distinct  jump,  and  if  a 


INJURIES   AND   DISEASES   OF   THE   PEOSTATE.  743 

Mercier  elbowed  catheter  goes  in  without  difficulty,  the  obstruction  is 
probably  one  caused  by  upward  projection  of  the  urethral  floor,  and 
its  distance  from  the  meatus  can  be  measured  by  the  solid  sounds. 
If  the  moderately  stiff  Mercier  catheter  will  not  pass,  but  a  very  small 
gum  catheter  or  one  of  the  rat-tail  pattern  enters,  the  urethra  is  prob- 
ably deflected  to  one  side  or  the  other.  If  all  instruments  enter 
readily,  but  the  outward  flow  of  urine  is  decidedly  interfered  with,  the 
obstruction  is  valvular. 

The  amount  of  residual  urine  is  determined  by  directing  the 
patient  to  empty  his  bladder,  and  then  introducing  a  soft  catheter  and 
drawing  off  w^iat  remains.  Normally  no  urine  should  flow  through 
this  catheter,  or  at  most  a  few  drops.  Measurements  of  the  urethral 
length  can  advantageously  be  made  during  this  portion  of  the  explo- 
ration. 

The  tonicity  of  the  bladder  is  estimated  by  the  force  with  which 
the  urine  is  propelled  through  the  catheter. 

The  cystoscope  is  serviceable  mainly  in  demonstrating  intravesical 
growths  about  the  bladder-neck,  in  enabling  the  surgeon  to  determine 
the  degree  of  cystitis,  and  in  affording  a  view  of  the  ureteral  orifices. 
From  observation  of  the  regularity  and  vigor  with  which  they  eject 
the  urine  an  estimation  as  to  the  functional  activity  of  the  kidneys 
may  be  made.  In  some  cases  it  may  be  possible  to  catheterize  the 
ureter,  and  thus  to  determine  absolutely  by  examination  of  the  drawn 
urine  the  condition  of  each  kidney  and  its  pelvis.  This  is,  however, 
likely  to  be  difficult  in  cases  of  enlarged  prostate. 

The  differential  diagnosis  of  obstruction  from  enlarged  prostate 
must  be  made  from  that  due  to  stricture,  to  chronic  posterior  ure- 
thritis, to  chronic  prostatitis  with  Contracture  of  the  internal  vesical 
sphincter,  to  calculus,  to  bladder-tumors,  to  vesical  atony,  and  to 
paralysis. 

In  stricture  there  is  a  small  stream  which  often  has  considerable 
force ;  in  prostatic  obstruction  the  stream  may  be  large,  but  is  with- 
out its  normal  parabolic  curve.  Stricture,  as  a  rule,  attacks  young 
men,  enlarged  prostates  are  chiefly  observed  in  old  men.  Stricture 
causes  obstruction  to  the  passage  of  the  instruments  within  six  and  a 
half  inches  of  the  meatus ;  the  obstruction  of  enlarged  prostate  is 
more  than  seven  inches  from  the  meatus.  There  is  no  increase  in 
urethral  length  in  stricture,  this  is  nearly  always  present  in  enlarged 
prostate. 

Chronic  posterior  urethritis  is  commonly  observed  in  young  and 
middle-aged  men,  and  is  often  a  sequel  to  gonorrhoea ;  there  is  little 
or  no  increase  in  the  size  of  the  prostate,  by  either  rectal  or  urethral 


744  GENITO-ITEINAEY   DISE.  SES   A:ND   SYPHILIS. 

examination ;  there  is  constantly  a  small  quantity  of  pus  in  the  urine, 
and  the  force  of  the  stream  is  not  markedly  diminished,  although  there 
may  be  trouble  in  starting  it  and  an  imperfect  cut-off.  There  is  no 
residual  urine. 

Chronic  prostatitis  associated  Avith  contracture  of  the  internal 
vesical  sphincter  is  especially  characterized  by  retention  of  urine, 
slowly  but  persistently  progressive  and  rarely  absolute — no  prostatic 
enlargement  is  found  either  by  rectal  palpation  or  urethral  examina- 
tion— the  urethral  length  may  be  shorter  than  normal,  and  the 
cystoscope  and  sound  fail  to  demonstrate  irregularities  about  the 
bladder  neck.  This  form  of  prostatitis  may  or  may  not  be  accom- 
panied by  the  symptoms  of  chronic  posterior  urethritis.  If  obstruc- 
tion to  instrumentation  is  detected  it  is  found  at  the  internal  vesical 
sphincter. 

Vesical  calculus  is  most  painful,  and  causes  most  marked  frequency 
of  urination  when  the  patient  is  up  and  about,  and  the  symptoms  are 
markedly  alleviated  by  rest  in  bed.  Unusually  severe  pain  and  tenes- 
mus, especially  if  associated  with  pus  and  blood  in  the  urine,  and  if 
paroxysmally  persistent,  should  always  suggest  the  presence  of  stone 
in  the  bladder.  Rectal  examination  and  instrumental  exploration  of 
the  bladder  should  at  once  establish  the  diagnosis,  since  a  calculus  can 
usually  be  readily  felt. 

Intravesical  tumor  may  closely  simulate  the  symptomatology  of 
enlarged  prostate.  Haematuria  is,  however,  pronounced,  and  becomes 
progressively  more  severe.  Rectal  and  cystoscopic  examinations  will 
establish  the  diagnosis. 

The  diagnosis  of  hypertrophied  prostate  from  atony  or  paralysis 
of  the  bladder  is  dependent  upon  the  history  of  the  case  and  upon 
exclusion  of  enlargement  of  the  prostate  by  rectal  and  urethral 
examination. 

The  clinical  classification  of  cases  of  prostatic  enlargement  should 
be  made  from  the  stand-point  of  the  degree  of  urinary  obstruction 
occasioned  by  the  gland  and  the  presence  or  absence  of  vesical  infec- 
tion. Retention  is  the  symptom  of  obstruction.  This  may  be  acute 
or  chronic,  partial  or  complete.  The  incomplete  chronic  retention 
may  or  may  not  be  accompanied  by  vesical  distention.  Any  of  these 
forms  of  retention  may  be  complicated  by  infection.  The  acute 
complete  retention  is  usually  observed  in  men  who  have  exhibited 
symptoms  of  moderate  obstruction  and  is  due  to  sudden  congestion 
of  the  prostate.  In  most  of  these  cases  there  has  been  a  previous 
long-standing  condition  of  incomplete  retention  with  or  without  bladder 
dilatation. 


INJUEIES   AND   DISEASES   OE   THE   PKOSTATE.  745 

Chronic  complete  retention  is  practically  always  accompanied  by 
vesical  dilatation.  In  this  condition  no  urine  is  passed  by  voluntary 
effort.  Chronic  incomplete  retention  implies  the  ability  partially  to 
empty  the  bladder,  a  residuum  being  left  which  may  not  greatly  in- 
crease if  the  bladder-walls  become  thickened  by  muscular  overgrowth 
or  inflammatory  infiltrate  and  organization,  or  which  may  gradually 
produce  enormous  distention,  the  overflow  then  passing  both  volun- 
tarily and  involuntarily. 

A  distended  bladder  is  prone  to  infection,  and  this  is  particularly 
true  of  a  viscus  which  has  not  been  subject  to  instrumental  treatment: 
hence  in  all  these  clinical  manifestations  of  obstruction  the  passage  of 
a  catheter  is  likely  to  be  followed  by  cystitis,  which,  once  started  in 
these  senile  and  obstructed  bladders,  is  exceedingly  hard  to  cure. 
The  presence  or  absence  of  cystitis  as  shown  by  the  symptoms  and 
by  the  examination  of  the  urine  has  a  distinct  bearing  on  treatment 
as  has  the  ascending  infection  represented  by  pyelitis  and  pyelo- 
nephritis. 

Retention,  if  progressive,  inevitably  results  in  vesical  atony  and 
distention,  and  ultimately  in  interstitial  nephritis  and  renal  insufficiency. 
At  times  it  is  accompanied  by  hemorrhage  from  the  dilated  veins  of 
the  prostatic  or  vesical  mucosa,  exceptionally  spontaneous,  usually  pro- 
voked by  instrumentation.  Inflammation  may  involve  the  mucous 
membrane  of  the  entire  genito-urinary  tract.  Cystitis,  though  usually 
first  excited  by  catheterism,  may  arise  independent  of  this,  and,  unless 
obstruction  be  removed,  ultimately  involve  the  ureter  and  renal  pelves. 
Vesical  calculus  is  a  common  sequel  of  cystitis  and  residual  urine,  and 
epididymitis  is  a  common  complication  of  catheterism  when  the  blad- 
der and  posterior  urethra  are  infected. 

Prognosis. — Aside  from  its  obstructive  effect  upon  the  urinary  flow 
and  its  tendency  towards  malignant  degeneration,  prostatic  over- 
growth is  a  harmless  affection.  When,  however,  the  function  of 
micturition  is  seriously  disturbed  and  the  obstruction  is  steadily 
increasing,  the  prognosis  in  the  absence  of  mechanical  treatment  is 
absolutely  bad.  Men  of  over  sixty  years  commonly  enough  exhibit  a 
symptom-complex  characterized  by  frequency  of  urination,  especially 
at  night,  slowness  in  starting  the  urinary  stream,  intermittence  and 
lack  of  force  in  its  propulsion,  and  dribbling  at  the  end.  On  rectal 
examination  the  prostate  shows  the  moderate  enlargement  common  at 
this  time  of  life,  and  on  catheterization  there  is  a  small  quantity  of 
residual  urine,  the  instrument  entering  the  bladder  easily  and  the 
urethra  not  being  lengthened.  This  condition  is  incident  rather  to 
senile   atrophy  of  the   vesical  detrusor  muscle   than  to   mechanical 


746  GENITO-UEIXAEY   DISEASES   AND   SYPHILIS. 

obstruction,  and  is  so  slowly  progressive  that  direct  treatment  is  rarely- 
required,  nor  in  itself  does  the  condition  seriously  threaten  the  general 
health. 

When  the  obstruction  is  sufficiently  pronounced  to  produce  reten- 
tion of  not  more  than  four  ounces,  and  there  is  no  infection,  the 
patient  may  remain  undisturbed  in  general  health  for  many  years. 
When,  however,  the  bladder  becomes  permanently  distended,  or  when 
cystitis  develops  either  with  or  without  distention  in  the  presence  of 
residuum,  the  prognosis  in  the  absence  of  treatment  is  absolutely  bad. 

Vesical  calculi  are  prone  to  develop  ;  atony  of  the  bladder  with 

hypertrophy  of  its  wall  almost  surely  ensues  ;  and  hydronephrosis  is  a 

common  sequel.     These  complications  greatly  intensify  the  gravity  of  a 

given  case. 

TREATMENT    OF   ENLARGED    PROSTATE. 

The  PALLIATIVE  treatment  of  enlarged  prostate  has  for  its  end  the 
maintenance  of  the  general  health  of  the  patient,  the  avoidance  of 
pelvic  and  renal  congestion,  and  the  adoption  of  measures  which  pre- 
vent intravesical  tension  and  avoid  infection,  or,  if  this  has  already 
developed,  apply  measures  appropriate  for  its  cure. 

Hygienic  Treatment. — Careful  attention  to  the  general  health 
Df  a  patient  suffering  from  prostatic  enlargement  is  of  cardinal  im- 
portance, since  comparatively  slight  disturbances,  such  as  acute  at- 
tacks of  indigestion,  exposure  to  cold,  or  excess  in  eating  and  drinking, 
may,  by  adding  the  element  of  acute  congestion  to  the  chronic  en- 
gorgement of  the  prostate,  bring  on  an  attack  of  retention,  which  may 
permanently  cripple  the  bladder.  The  diet  must  be  carefully  regu- 
lated, the  needs  and  idiosyncrasies  of  each  patient  being  considered. 
In  general,  sweets,  pastries,  exclusively  nitrogenous  diets,  and  highly 
spiced  foods  should  be  avoided.  Alcohol  may  be  taken  in  moderation, 
well  diluted,  after  meals,  though  it  should  be  allowed  only  when  the 
general  atonic  condition  of  the  patient  indicates  that  it  is  likely  to  be 
useful ;  in  robust  individuals  its  use  should  be  prohibited.  Thompson 
highly  approves  of  cider  in  certain  cases.  This  should  be  neither 
sweet  nor  markedly  acid.  Milk,  buttermilk,  effervescing  alkaline 
mineral  waters,  are  all  serviceable.  Smoking  in  moderation,  if  it  has 
been  a  habit,  need  not  be  interdicted.  Among  the  articles  of  food 
which  should  be  strictly  forbidden  are  pork  in  all  its  forms,  cheese, 
raw  fruits,  and  sugars.  Most  careful  attention  should  be  paid  to  the 
condition  of  the  bowels,  and  regular  evacuation  should  be  secured 
daily  by  the  use  of  Vichy  or  Hunyadi  water  or  enemata. 

Clothing  should  be  regulated  in  accordance  with  the  weather, 
chilling  of  the  surface  being  particularly  avoided.     The  acute  conges- 


INJUKIES   AND   DISEASES   OF   THE   PllOSTATE.  747 

tive  attacks  so  common  in  the  course  of  chronically  enlarged  pros- 
tate are  especially  apt  to  result  from  cold,  wet  feet.  The  skin  should 
be  kept  in  good  condition  by  daily  cold  sponging  followed  by  brisk 
rubbing  with  a  flesh-brush.  Moderate  exercise  in  the  air  is  always 
serviceable ;  in  some  cases  horseback  riding  is  attended  by  no  ih 
effects  ;  in  other  cases  the  jolting  markedly  increases  congestion,  as  is 
evidenced  by  obstructive  symptoms.  Walking,  driving,  the  use  of 
gymnastic  apparatus,  calisthenic  motions  employed  regularly,  are  all 
serviceable. 

The  sleeping  hours  should  be  sufficient  for  rest,  but  long  lying  in 
bed  should  be  discouraged.  Prostatic  patients  are  always  better 
v/hen  they  are  up  and  about.  When  the  patient  is  much  annoyed 
by  frequent  urination  at  night,  a  hot  bath  before  retiring  will  be  found 
serviceable. 

The  most  frequent  and  most  potent  causes  of  pelvic  engorgement, 
and  hence  of  sudden  increase  in  the  obstructive  symptoms  due  to  en- 
larged prostate,  are — 1.  Retaining  the  urine  for  a  considerable  period 
after  the  desire  to  urinate  becomes  urgent.  2.  Chilling  of  the  surface. 
3.  Sexual  excitement.  4.  Over-indulgence  in  eating  and  in  the  use  of 
alcohol.     5.  Constipation. 

The  therapeutic  or  rather  prophylactic  indications  are  sufficiently 
plain. 

Medicinal  Treatment. — Of  the  drugs  which  may  be  employed 
with  any  hope  of  benefit  in  cases  of  enlarged  prostate  but  little  can 
be  said.  No  drug  seems  to  have  a  specific  influence  upon  the  pros- 
tate, unless  it  is  ergot,  which  is  administered  on  the  plausible  theory 
that  this  gland,  being  possibly  the  analogue  of  the  uterus,  may  re- 
spond in  a  similar  manner  to  similar  influences.  Ergot  may  be  bene- 
ficial where  hypertrophy  of  the  muscular  elements,  as  shown  by  the 
softness  of  the  gland,  predominates.  It  should  be  used  merely  as 
an  auxiliary  to  other  treatment.  Salol,  boric  acid,  and  saw-palmetto, 
with  belladonna  and  the  bromides,  will  often  be  serviceable  in  the 
treatment  of  the  inflammatory  comphcations  of  hypertrophied  pros- 
tate, notably  cystitis.  Sodium  iodide  in  doses  of  three  grains,  three 
times  a  day,  is  valuable  as  a  means  of  retarding  the  development  of 
.  arterio-sclerosis,  which  so  commonly  complicates  prostatic  hyper- 
trophy, and  hyoscine  or  hyoscyamine  seems  to  exert  a  favorable  influ- 
ence on  the  function  of  micturition. 

Intermittent  Dilatation. — A  patient  who  presents  the  symptoms 
of  a  prostato-vesical  congestion  of  the  early  stages  of  hypertrophy, 
who  is  disturbed  once  or  twice  at  night,  who  has  an  enlargement  of 
moderate  density,  appreciable  through  the  rectum,  but  not  offering 


748  GEXITO-URIXAKY   DISEASES   AXD    SYPHILIS. 

much  resistance  to  the  introduction  of  an  ordinary  catheter,  and  who 
has  but  httle  residual  urine,  is  likely  to  derive  great  benefit  from  the 
systematic  introduction  of  full-sized  steel  sounds.  This  treatment, 
and  this  alone,  often  reheves  existing  symptoms,  and  prevents,  or,  at 
least,  delays  the  development  of  further  trouble.  That  it  can  have 
any  curative  effect  is  unlikely  ;  that  it  can  even  modify  to  any  extent 
the  continuous  enlargement  of  the  gland  seems  improbable  ;  but  that, 
either  by  producing  a  local  atrophy  in  the  parts  immediately  surround- 
ing the  urethra,  or  by  simply  stretching  the  canal  itself  and  relieving 
local  congestion  and  tumefaction,  it  mitigates  the  early  symptoms, 
lessens  the  vesical  irritability,  diminishes  the  amount  of  residual  urine, 
and  modifies  favorably  the  whole  course  of  the  case,  is  beyond  all 
doubt.  The  largest  steel  sound  which  the  membranous  urethra  will 
permit  to  pass  is  introduced  every  fifth  day,  and  is  allowed  to  remain 
in  place  for  ten  to  fifteen  minutes,  or  longer  if  the  patient  is  in  bed. 
Preliminary  irrigation  of  the  urethra,  careful  sterilization  of  the  instru- 
ment, and  gentleness  in  its  introduction  render  the  treatment  free 
from  objection,  and  intelligent  patients  carry  it  on  for  themselves  for 
years. 

Rectal  Injections. — These  may  be  hot  or  cold,  as  the  patient 
prefers,  and  may  be  of  normal  saline  solution  when  ordinary  water 
congests  and  irritates  the  mucous  membrane  of  the  rectum.  The 
stream  of  water  should  be  thrown  forcibly  upward  and  forward  di- 
rectly against  the  prostate,  and  the  injecting-pipe  should  be  provided 
^•■ith  openings  through  which  the  liquid  escapes  at  once  without  dis- 
tending the  rectum. 

Massage  is  useful,  not  so  much  because  it  causes  shrinking  of  the 
prostate  as  because  of  its  tonic  effect  upon  the  walls  of  the  blood- 
vessels, thus  diminishing  congestion  and  rendering  the  circulation 
more  normal.  Sometimes  it  seems  to  irritate  the  prostate  ;  in  this 
case  it  should  be  discontinued.  It  is  particularly  serviceable  in  the 
treatment  of  prostatism  associated  with  small  prostates. 

Catheterism. — The  catheter  is  used  for  the  relief  of  retention. 
It  may  be  required  occasionally,  as  in  cases  of  acute  retention  without 
distention,  habitually,  as  in  cases  of  chronic  retention  with  or  without 
distention,  or  continuously,  as  in  cases  of  infection  with  systemic 
absorption.  In  using  a  catheter  for  the  relief  of  retention  that  instru- 
ment should  be  selected  which  enters  the  bladder  most  easily,  usually 
an  elbowed  soft  rubber  catheter.  Each  introduction  should  be  pre- 
ceded by  urethral  irrigation,  preferably  Avith  protargol  solution  1  to 
2000,  since  the  anterior  urethra  is  always  infected.  (For  details  of 
Catheterism,  see  page  317.)     All  forms  of  urinary  retention  caused  by 


INJUKIES   AND   DISEASES   OF   THE   PROSTATE.  749 

enlarged  prostate  are  amenable  to  treatment  by  regular  cleanly  cathe- 
terization, and  in  those  cases  characterized  by  acute  complete  retention 
this  treatment  may  be  curative,  at  least  to  such  an  extent  that  the 
patient  is  again  able  to  void  liis  urine  and  is  troubled  only  by  fre- 
quency, some  loss  of  power  in  the  stream,  and  a  residuum  too  insig- 
nificant to  produce  symptoms.  In  all  other  forms  of  retention,  either 
with  or  without  infection,  the  catheter  may  serve  a  useful  purpose  in 
delaying  the  progression  of  symptoms  and  saving  the  kidneys  from 
irremediable  damage. 

On  general  principles  it  should  be  used  for  the  relief  of  complete 
retention  as  often  as  is  needful  to  prevent  the  bladder  from  containing 
more  than  twelve  ounces  at  a  time  ;  in  incomplete  retention  once  in 
twenty-four  hours  for  each  four  ounces  of  residuum  contained  by  the 
bladder.  It  should  be  supplemented  by  mild  antiseptic  urethral  and 
vesical  irrigations,  and  these  are  absolutely  indicated  in  the  presence 
of  cystitis.  In  the  latter  case,  vesical  irritability  associated  with 
inability  to  pass  any  water  at  all,  or  at  most  a  few  drops,  may  require 
the  use  of  the  catheter  much  more  frequently,  this  being  particularly 
the  case  when  there  is  incomplete  retention  in  a  non-distended  infected 
bladder. 

When,  because  of  back  pressure  or  infection,  or  a  combination  of 
these  conditions,  renal  insufficiency  develops,  characterized  by  gastro- 
intestinal breakdown,  hebetude  or  somnolence,  and  other  ursemic 
manifestations,  or  by  septic  fever,  continuous  catheterization  is  pecu- 
liarly serviceable.  The  objections  to  habitual  catheterism  in  chronic 
prostatics  are  the  risks  of  vesical  infection  and  the  production  of 
chronic  atony.  These,  though  serious,  are  not  sufficient  to  contra- 
indicate  the  employment  of  the  method  under  all  circumstances. 

Infection  may  often  be  avoided  by  the  administration  of  moderate 
doses  of  urinary  antiseptics  by  the  mouth,  salol  being  particularly  ser- 
viceable, but  in  doses  so  small  as  not  to  irritate  the  kidneys,  and  by 
scrupulous  and  unflagging  care  as  to  asepsis.  Vesical  atony  is  avoided 
rather  than  encouraged  by  systematic  catheterism,  and  though  the 
average  expectation  of  life  of  a  patient  beginning  the  habitual  use  of 
the  catheter  is  not  over  five  years,  in  selected  cases — if  the  method  can 
be  intelligently  applied,  causes  no  discomfort,  and  is  not  followed  by 
infection — it  may  be  continued  with  safety  for  many  years. 

The  complications  incident  to  catheterization  are  :  difficulty  in  the 
introduction,  either  mechanical  or  incident  to  pain,  in  the  latter  case 
greatly  relieved  by  preliminary  instillations  of  four  per  cent,  eucaine 
solution ;  urethritis,  prevented  by  irrigation  each  time  the  instrument  is 
passed  ;  epididymitis,  prevented,  if  recurring,  by  vasectomy ;  and  hem- 


750  GENITO-rRIXAET   DISEASES   A2s^D   SYPHILIS. 

orrhage,  avoided  by  the  proper  selection  of  the  instrument  and  extreme 
gentleness  :  and  infection,  prevented  by  antiseptic  irrigations  and  clean- 
liness. 

As  a  rule,  when  habitual  use  of  the  catheter  is  required,  the 
patient's  best  interests  will  be  consulted  by  advising  operation.  This 
may  take  the  form  of — 

1.  Over-dilatation  of  the  internal  vesical  sphincter,  applicable  to 
cases  of  smallhard  prostates,  complicated  by  sclerosis  of  the  sphincter. 

2.  Prostatotomy,  or  incision  of  the  internal  vesical  sphincter  and 
prostate,  particularly  applicable  in  the  small  sclerosed  prostate. 

3.  Prostatectomy,  or  total  enucleation  of  the  prostate  gland,  ap- 
plicable to  all  cases  of  prostatism  complicated  by  an  increasing  re- 
siduum with  or  without  distention  of  the  bladder  or  with  or  without 
infection. 

4.  Cystostomy,  applicable  to  cases  of  inveterate  cystitis,  in  which 
the  systemic  condition  is  such  as  to  make  unjustifiable  the  more  radical 
procedure. 

5.  Castration  or  vasectomy,  applicable  to  those  cases  suffering 
from  enlarged  prostate  who  properly  should  be  subjected  to  radical 
procedure  but  who  reject  the  knife,  and  especially  if  efficient  drainage 
by  either  intermittent  or  continuous  catheterization  is  also  not  prac- 
ticable ;  to  some  cases  obviously  unable  to  bear  the  shock  of  prosta- 
tectomy ;  and  occasionally  (vasectomy)  as  a  prehminary  or  possible 
palliative  when  a  later  radical  operation  is  contemplated. 

Before  any  form  of  operative  treatment  is  undertaken,  a  careful 
examination  of  the  urine  should  be  made  to  determine  whether  or  not 
the  kidneys  are  competent.  This  should  include  an  estimate  of  the 
urea  excreted  in  twenty-four  hours,  together  with  findings  of  the  usual 
chemical  and  microscopical  examination  of  the  urine  and  the  results 
of  the  phloridzin  test.  (See  page  383.)  If  renal  insufficiency  is  thus 
demonstrated,  an  effort  should  be  made  to  bring  the  kidneys  to  their 
highest  functionating  power  before  operation.  This  is  best  accom- 
plished by  attention  to  general  hygiene,  a  milk,  buttermilk,  or  koumiss 
diet,  Avith  as  much  water  as  can  be  taken  without  disturbing  the  stom- 
ach, and  high  rectal  enemata  of  normal  salt  solution  at  body  tempera- 
ture. Moreover,  it  is  of  major  importance  under  these  circumstances 
entirely  to  relieve  the  kidneys  of  back  pressure  and  to  provide  ade- 
quate drainage  in  cases  of  cystitis  complicated  by  infection  of  the 
renal  pelvis.  This  is  most  safely  accomplished  by  continuous  catheter- 
ization. When  the  use  of  the  catheter  is  impracticable,  cystostomy 
may  be  needful.  If,  in  spite  of  these  means  and  others  having  for 
their  end  tlie  betterment  of  the  patient's  general  condition,  the  kidneys 


INJURIES   AND    DISEASES   OF   THE    PROSTATE.  75I 

remain  incompetent,  it  is  unwise  to  insist  upon  an  operation  as  radical 
as  that  or  total  enucleation.  If,  however,  by  such  a  treatment  the  sys- 
temic symptoms  of  infection  and  of  uraemia  lessen  or  disappear  and 
the  urinary  secretion  becomes  adequate,  neither  age  nor  vesical  nor 
renal  inflammation  nor  other  complications  of  enlarged  prostate  should 
prevent  the  performance  of  the  radical  operation. 

Stretching  of  the  Internal  Vesical  Sphincter. — This  is  indicated 
in  those  cases  of  prostatism  without  prostatic  enlargement.  The  ob- 
struction to  the  urinary  flow  is  here  due  to  a  sclerosed  condition  of 
the  internal  vesical  sphincter,  a  muscle  which  in  its  normal  state 
relaxes  when  the  bladder  contains  three  or  four  ounces  of  urine. 
This  sphincter  should  admit  the  index-finger,  but  when,  as  a  con- 
sequence of  chronic  prostatitis  or  inflammation  about  the  vesical  neck, 
it  undergoes  probably  first  hypertrophy  and  afterward  fibroid  degen- 
eration, it  forms  a  narrow  hard  ring  into  which  the  tip  of  the  little 
finger  can  be  passed  only  with  difficulty,  though  it  may  admit  a  28 
sound  passed  through  the  urethra  with  only  a  slight  sense  of  re- 
sistance. 

This  operation  may  be  accomplished  under  nitrous  oxide  by  means 
of  a  dilating  instrument  which  we  have  had  constructed,  especially 
for  this  purpose,  the  extreme  calibre  of  which  is  seventy-five  milli- 
metres. (Fig.  63.)  Stretching  to  forty-five,  the  extreme  calibre  of 
the  usual  prostatic  dilator,  is  entirely  inadequate. 

In  employing  this  treatment  the  urethra  and  bladder  are  first 
flushed  with  1  to  2000  protargol  solution.  The  distance  from  the 
meatus  to  the  internal  vesical  sphincter  is  carefully  measured  and 
the  instrument  is  introduced  so  that  its  dilating  part  lies  exactly 
within  the  grip  of  this  muscle.  Its  position  can  be  further  assured  by 
the  finger  of  an  assistant  in  the  rectum.  The  patient  is  then  given 
nitrous  oxide  and  the  screw  in  the  handle  is  rapidly  turned  until  the 
dilating  part  reaches  its  full  calibre.  Excepting  for  the  use  of  a 
bland  diet  and  urinary  antiseptics  by  the  mouth,  there  is  no  after- 
treatment. 


PROSTATOTOMY. 

By  this  term  is  meant,  incision  through  the  internal  vesical  sphincter 
and  into  the  substance  of  the  prostate.  It  may  be  made  either  with 
the  knife  or  with  the  galvano-cautery  instrument  through  a  perineal 
incision  or  through  the  urethra  (Bottini's  operation).  Each  has  for 
its  end,  the  removal  of  obstruction,  by  direct  division  in  one  case  and 
by  division  supplemented  by  extensive  sloughing  in  the  other.     Both 


752  GENITO-UKIJNfAKY   DISEASES   AND   SYPHILIS. 

are  especially  applicable  to  small  hard  prostates  complicated  by  reten- 
tion and  probably  by  sclerosis  and  contracture  of  the  internal  vesical 
sphincter,  though  the  advocates  of  the  Bottini  operation  claim  for  its 
proper  application,  usefulness  in  nearly  all  forms  and  degrees  of  pros- 
tatic enlargement. 

Perineal  prostatotomy  performed  hy  the  hnife  is  useful  in  pro- 
viding an  efficient  route  for  permanent  drainage  of  the  bladder,  this 
procedure  being  especially  indicated  in  those  conditions  of  cystitis  so 
pronounced  that  permanent  catheterization  is  either  unbearable  or 
inefficient,  and  associated  with  a  contracted,  rigid,  and  inflamed  blad- 
der too  small  to  be  readily  drained  by  the  formation  of  a  suprapubic 
fistula. 

Perineal  prostatotomy  can  be  performed  under  local  anaesthesia  ;  it 
is,  however,  better  to  employ  nitrous  oxide,  since  not  more  than  one 
or  two  minutes  are  required  for  the  completion  of  the  operation. 

After  preliminary  antiseptic  irrigation  of  the  bladder,  a  grooved 
staff  is  passed,  and  upon  this,  by  an  inch  l(jng  incision  passing  through 
the  perineal  centre,  the  membranous  urethra  is  opened.  The  point 
of  the  knife  engaging  in  the  groove  of  the  staff,  the  blade  is  passed 
into  the  bladder  and  then  withdrawn,  cutting  forward  and  backward 
through  the  internal  sphincter  and  into  the  substance  of  the  prostatic 
commissure.  The  finger  should  then  be  passed  along  the  staff  and 
the  latter  withdrawn.  Thereupon  the  interior  of  the  bladder  may  be 
palpated.  The  vesical  neck  should  be  further  dilated  to  at  least  74  F. 
when  the  obstruction  is  due  to  contracture  of  the  internal  vesical 
sphincter.  This  may  be  accomplished  by  Spencer  Wells  forceps  or  a 
uterine  dilator.  A  drainage-tube  fully  the  size  of  the  little  finger  and 
rigid  should  be  so  secured  that  its  inner  opening  is  just  within  the 
bladder,  and  to  this  tub&  should  be  connected  a  urinal  placed  at  a 
level  sufficiently  low  to  drain  the  bladder.  When  it  is  intended  to 
establish  a  permanent  fistula,  Watson's  tube  of  hard  rubber  and  de- 
signed especially  for  this  operation  will  be  f6und  most  efficient.  When 
the  drainage  is  meant  to  be  temporary,  the  largest  size  soft  rubber 
catheter  (30  F.)  will  be  found  serviceable.  Exceptionally,  hemorrhage 
is  so  severe  as  to  require  packing.  The  bladder  is  irrigated  at  least 
.  twice  daily  with  silver  solution.  The  patient  need  not  be  kept  in  bed 
for  more  than  a  day  unless  this  be  indicated  by  his  general  condition. 

A  perineal  fistula  is  less  desirable  than  one  placed  suprapubicly, 
and  should  be  formed  as  a  permanent  palliative  measure  only  when 
the  latter  is  impracticable. 

Gal vano- cautery  Prostatotomy  through  a  Perineal  Open- 


INJUEIES   AND   DISEASES    OF    THE    PROSTATE. 


753 


ing. — Chetwood  has  suggested  galvano-cautery  incision  through  a  perin- 
eal opening.  His  instrument  (Fig.  236)  resembles  that  devised  by  Bot- 
tini,  but  the  blade  is  drawn  out  by  a  direct  pull  to  a  stop-pin  which  is  set 
at  the  desired  point.  The  results  are  verified  by  digital  exploration. 
Moreover,  complications  may  be  more  readily  treated  and  the  danger 
of  urinary  extravasation  from  an  incision  carried  into  the  membranous 
urethra  is  entirely  obviated.  The  thorough  exploration  allowed  by  the 
perineal  opening,  enables  the  surgeon  to  pro-  ^^ 

ceed  at  once  to  a  complete  prostatectomy  in 
case  this  be  deemed  advisable. 

Perineal  section  is  performed  and  the 
urethra  is  opened  transversely  at  the  apex 
of  the  prostate.  By  digital  exploration  the 
exact  condition  of  the  gland  and  the  bladder 
is  determined,  and  the  Icngtii,  depth,  and 
location  of  the  incisions  are  estimated.  The 
blade  for  the  cut  is  then  selected,  put  in  the 
staff,  and  the  stop-pin  is  put  in  position  on 
the  handle.  The  instrument  having  been 
tested  is  introduced  through  the  urethral 
wound.  With  the  index-finger  in  the  rectum, 
the  beak  is  made  to  hug  snugly  against  the 
obstruction,  the  current  is  turned  on,  and 
after  the  required  number  of  seconds  as  pre- 
viously determined  to  produce  white  heat, 
the  handle  is  slowly  pulled  out  to  the  stop- 
pin,  the  blade  is  then  slowly  returned  to  its 
position  in  the  beak,  and  the  current  is 
turned  off.  The  rate  of  cutting  should  not 
be  more  than  half  an  inch  per  minute. 
Burning  of  the  bladder  is  avoided  by  a 
stream  of  cold  salt  solution  running  through 
the  urethra  and  into  the  perineal  wound. 
After  operation  the  bladder  is  irrigated,  the 
perineal  drainage-tube  is  secured  in  place, 
and  treatment  thereafter  is  that  indicated 
after  perineal  prostatectomy. 

Bouffleur  has  modified  the  galvano-cau- 
tery  operation  by  performing  it  through  a  suprapubic  cystotomy 
incision,  using  the  actual  cautery  heated  to  white  heat.  The  in- 
cision is  thus  made  directly  under  the  guidance  of  the  eye  and 
fmger. 


Chetwood's  galvano  cautery 
prostatic  Incisor. 


754  GEXITO-URIXARY    DISEASES   AXD    SYPHILIS. 

PROSTATECTOMY. 

Total  removal  of  the  gland  is  indicated  in  all  cases  of  pronounced 
enlargement  with  symptoms  of  progressively  increasing  urethral  ob- 
struction. The  softer  and  larger  the  gland  the  easier  and  safer,  as  a 
rule,  is  the  operation.  Sma.ll  dense  fibroid  prostates,  particularly 
those  which  are  the  seat  of  chronic  inflammation,  are  least  amenable 
to  this  treatment,  the  difficulties  of  removal  being  great  and  the  oper- 
ative sequelae  being  frec^uently  unsatisfactory. 

The  gland  may  be  removed  through  a  suprapubic  opening,  the 
operation  being  conducted  mainly  by  the  guidance  of  touch  ;  through 
a  small  vertical  perineal  opening,  the  operation  being  conducted  en- 
tirely by  the  guidance  of  touch  :  or  through  a  transverse  curved  peri- 
neal opening,  the  operation  being  directed  by  both  the  senses  of  touch 
and  sight. 

Prostatectomy  is  the  procedure  of  election  when  operative  inter- 
ference is  indicated,  when  the  kidneys  are  competent  or  can  be  made 
so  by  appropriate  treatment,  and  the  patient's  general  condition  is  such 
as  to  enable  him  to  endure  a  major  operation.  The  operation  should 
be  delayed  in  the  presence  of  severe  acute  infection,  either  local  or 
constitutional,  until  by  diet,  urmary  antiseptics,  systemic  treatment  and 
drainage,  and  irrigation  of  the  bladder  this  condition  is  bettered.  This 
drainage  is  most  easily  employed  in  the  form  of  continuous  catheter- 
ization. Where  this  is  not  applicable,  suprapubic  or  perineal  drainage 
may  be  secured  in  a  few  minutes  by  means  of  either  local  anaesthesia, 
or,  better  still,  the  administration  of  nitrous  oxide. 

As  to  the  choice  of  operation,  it  is  apparent  that  by  either  route 
the  great  majority  of  prostates  can  be  removed.  The  small  sclerosed 
prostate,  the  capsule  of  which  is  densely  adherent  to  the  fibrous  sheath, 
can  probably  be  most  safely  reached  and  enucleated  through  a  trans- 
verse perineal  opening.  Soft  fibro-glandular  prostates,  the  lobules  of 
which  are  readily  shelled  out  from  the  surrounding  stroma  and  the 
lobes  of  which  are  easily  enucleated  from  the  investing  sheath,  can  be 
readily  and  safely  enucleated  by  any  one  of  the  three  methods. 

In  general  terms,  when  there  is  a  narrow,  deep  perineum,  a  greatly 
elongated  urethra,  and  the  prostatic  enlargement  is  placed  so  high  as 
to  be  reached  with  difficulty  by  rectal  examination,  the  suprapubic 
operation  would  seem  indicated.  The  experience  and  aptitude  of  the 
operator  Avith  the  method  to  which  he  is  accustomed  is  of  far  greater 
importance  in  determining  the  choice  of  procedure  than  the  character 
of  the  prostatic  enlargement. 

Suprapubic  Prostatectomy. — The  transvesical  route  has  been 


INJUKIES   AND    DISEASES  OF   THE    PEOSTATE.  755 

popularized  in  England  by  Freyer,  who,  adopting  the  technique  of 
Fuller,  has  obtained  admirable  results.  In  this  country  the  perineal 
operation  is  the  more  popular,  since  it  is  attended  by  a  distinctly  lower 
mortality,  and  since  it  enables  the  surgeon  to  remove  practically  all  the 
prostate  and  spare  the  prostatic  urethra.  The  removal  of  this  latter 
tube,  however,  seems  to  have  no  evil  effect  upon  the  ultimate  result. 

On  general  principles,  the  suprapubic  operation  is  somewhat  easier 
for  the  removal  of  large  intravesical  growths  or  pedunculated  lobes. 
Moreover,  this  method  enables  the  surgeon  to  explore  the  bladder 
thoroughly  both  by  sight  and  touch.  Impotence,  permanent  urinary 
incontinence,  and  urinary  fistulae  are  rarer  sequelae  of  this  operation 
than  of  the  perineal  incision.  In  very  fat  persons  and  in  those  with 
extremely  contracted  bladders,  the  suprapubic  operation  is  to  an  extent 
contra-indicated. 

The  position  of  the  patient  during  the  performance  of  this  opera- 
tion should  be  that  for  suprapubic  lithotomy.  The  instruments  re- 
quired are  scalpels,  hsemostats,  tissue  forceps,  retractors,  curved  and 
straight  needles,  ordinary  straight  and  curved  scissors,  silkworm  gut, 
polyp  or  prostatic  grasping  forceps,  sounds,  rubber  catheters,  an  irri- 
gator, and  a  siphon  drainage  apparatus. 

Immediately  before  operation  the  bladder  is  irrigated  with  pro- 
targol  solution  1  to  2000,  from  six  to  twelve  ounces  of  which  are  left 
in  the  bladder,  according  to  its  capacity.  The  patient  in  the  dorsal 
decubitus  is  elevated  to  the  Trendelenburg  position,  and  an  incision  is 
made  directly  in  the  median  line,  beginning  at  the  symphysis  and  ex- 
tending upward  two  inches.  In  fat  people  the  incision  is  lengthened 
upward  through  the  subcutaneous  tissue.  The  sheath  of  the  rectus 
and  the  layer  of  transversalis  fascia  bounding  the  anterior  surface  of 
the  prevesical  space  are  cut  through,  thus  exposing  the  bladder  and 
the  fatty  tissue  and  venous  plexus  overlying  it.  An  incision  is  made 
in  this  fatty  tissue  in  such  a  way  as  to  avoid  the  large  veins,  and  the 
bladder-wall  is  exposed  and  held  up  by  a  silk  suture  passed  by  a  curved 
needle  across  the  middle  of  the  proposed  vesical  incision.  The  division 
of  the  bladder-wall  is  made  by  an  inch  cut  midway  between  entrance 
and  the  exit  of  this  suture,  the  mid-portion  of  which  is  pulled  through 
the  wound  and  divided,  thus  leaving  a  thread  retractor  on  each  side 
of  the  wound.  The  fluid  contents  of  the  bladder  are  then  entirely 
removed  either  by  suction  or  sponges,  allowing  the  interior  of  this 
viscus  to  be  thoroughly  inspected,  a  small  electric  light  rendering  this 
part  of  the  examination  easy.  The  prostate  should  be  made  prom- 
inent by  the  finger  of  an  assistant  in  the  rectum.  The  vesical  orifice 
is  located  by  means  of  a  catheter  passed  through  the  urethra.     The 


756  GENITO-URIXAKY   DISEASES   AND   SYPHILIS. 

thin  bladder-wall  over  the  projecting  lobe  is  cut  for  half  an  inch  to  an 
inch  by  means  of  long  handled  straight  scissors,  the  incision  being 
placed  a  little  to  the  side  of  the  urethral  orifice  and  just  back  of  it. 
The  finger  is  then  passed  through  this  opening  and  carefully  strips  off 
first  the  mucous  membrane  of  the  bladder  and  then  the  prostatic 
sheath  from  the  capsule  of  the  gland.  It  is  important  in  this  enuclea- 
tion to  keep  the  finger  close  to  the  capsule  and  not  to  allow  it  to  tear 
the  fibrous  investing  sheath  in  which  lie  many  large  veins.  This  plexus 
is  particularly  well  developed  at  the  sides  and  the  anterior  surface  of 
the  prostate.  When  the  lobe  is  partly  free  its  further  enucleation  may 
be  facilitated  by  seizing  its  end  in  broad  traction  forceps  and  drawing 
upon  it  while  the  finger  strips  it  of  adhesions.  It  is  sometimes  pos- 
sible to  enucleate  the  entire  prostate  in  one  mass.  In  this  case  it  is 
probable  that  the  prostatic  urethra  comes  Avith  the  gland.  Usually  two 
lateral  lobes  are  removed  separately.  The  central  lobe  or  commissure 
may  be  attached  to  one  or  the  other.  In  many  cases  the  prostatic 
urethra  is  often  extensively  lacerated  or  may  be  removed  entirely. 
There  seems  reason  to  believe  that  it  is  sometimes  left  intact,  but 
necessarily  with  some  prostatic  substance.  In  the  dense  small  pros- 
tates, total  removal  of  the  gland  will  be  quite  impossible  without  pro- 
ducing extensive  tears  of  the  investing  fascia.  Under  such  circum- 
stances the  prostate  should  be  removed  piecemeal  by  an  appropriate 
cutting  and  pinching  instrument.  This  procedure  is  distinctly  less 
serviceable  than  total  enucleation.  The  catheter  lying  in  the  bladder 
guides  the  surgeon  as  to  the  position  of  the  prostatic  urethra,  which 
should  be  preserved  if  possible.  During  this  operation  there  is  some- 
times profuse  hemorrhage  due  to  tearing  of  the  investing  fibrous  tissue. 
It  is  best  checked  by  firm  pressure  made  with  packing  soaked  in  ad- 
renalin solution  1  to  5000.  Exceptionally,  it  is  needful  to  make  a 
free  opening  and  apply  haemostats.  The  patulousness  of  the  urethra 
is  determined  by  a  full-sized  rubber  catheter  which  is  allowed  to  remain 
for  drainage.  The  operation  is  completed  by  thorough  irrigation  of 
the  bladder  and  fairly  close  suture  of  the  walls  of  this  viscus  around 
a  suprapubic  drainage-tube  which  should  be  attached  to  a  siphon 
apparatus.  (See  page  480.)  The  parietal  wound  is  closed  with  tube 
or  wick  drainage  of  the  prevesical  space.  There  is  always  some  post- 
operative bleeding  lasting  one  or  two  days ;  as  a  rule,  moderate  in 
degree,  very  exceptionally  profuse,  and  resulting  fatally. 

Prostatectomy  by  Median  Perineal  Incision. — This  opera- 
tion is  particularly  indicated  in  large  soft  prostatic  overgrowths  extend- 
ing toward  the  rectum.  It  is  practicable,  however,  to  make  a  complete 
operation,  even  though  the  direction  of  growth  be  distinctly  intra- 


INJURIES   AND   DISEASES    OF   THE    PROSTATE. 


757 


vesical.  The  dense  fibrous  sclerotic  hypertrophy  in  which  the  capsule 
of  the  gland  is  likely  to  be  closely  adherent  to  the  periprostatic  sheath 
is  more  readily  and  safely  removed  by  a  transverse  perineal  incision 
under  the  guidance  of  the  eye  and  finger.  The  patient  is  placed  in 
the  lithotomy  position,  and  after  the  customary  cleansing  of  the  blad- 
der a  grooved  staff  is  passed  and  an  incision  is  made  from  the  scroto- 
perineal  junction  to  within  half  an  inch  of  the  anus  directly  in  the 
middle  line.  (Fig.  237.)  This  incision  is  deepened,  dividing  the  peri- 
neal centre  until  the  membranous  urethra  is  exposed.  This  is  incised, 
the  cut  passing  back  through  the  lower  part  of  the  prostatic  urethra,  and 
the  finger  is  introduced  through  the  prostate  into  the  bladder  if  this  be 
possible.     The  opening  is  sufficiently  dilated  to  allow  the  introduction 

Fig.    237. 


Various  perioeal  incisions. 


of  the  blade  of  a  pair  of  scissors,  by  which  means  a  transverse  incision 
is  made  in  the  urethral  floor  at  or  a  little  back  of  the  apex  of  the 
prostate.  (Fig.  238.)  The  finger  is  then  introduced  into  this  incision, 
working  its  way  between  the  capsule  of  the  gland  and  the  outer  fibrous 
investment.  Young's  tractor  (Figs.  245-6)  will  be  found  serviceable  in 
separating  the  posterior  portion  of  the  lateral  lobes  and  the  large  middle 
lobe,  or  these  portions  of  the  gland  may  be  made  accessible  by  a  finger 
in  the  rectum.  Guiteras  advises  the  use  of  a  prostatic  elevator  shaped 
somewhat  like  a  stove-lid  lifter.  When  the  gland  is  sufficiently  loosened 
its  anterior  part  is  seized  with  forceps  and  drawn  out,  thus  allowing 
more  ready  separation  of  the  deeper  parts.  This  operation,  if  con- 
ducted with  care,  is  attended  by  little  bleeding  and  does  not  seriously 
endanger  the  rectum.    It  is  rapid,  but  is  more  likely  to  secure  enuclea- 


758 


GENITO-UKINAKY    DISEASES    A^s^D   SYPHILIS. 


tion  of  enlarged  lobules  than  of  the  entire  gland,  unless  the  prostatic 
urethra  is  also  sacrificed.  Removal  of  the  middle  lobe  may  be  ex- 
tremely difficult,  though  this  usually  comes  out  with  one  or  other  of 
the  lateral  lobes.     It  is  conducted  entirely  by  the  sense  of  touch. 

After  removal  of  the  prostate,  the  bladder  and  prostatic  bed  are 
thoroughly  irrigated,  an  irrigating  drainage-tube  is  introduced,  and  the 
parietal  wound  is  closed  by  suture.     (Fig.  252.)     The  bladder  is  irri- 


Fir 


^ 


Prostatectomy  through  retracted  edges  of  median  incision.    ("Ferguson.) 

gated  continuously  with  protargol  solution  1  to  2000  for  twelve  hours, 
after  which  the  drainage-tube  is  removed  and  the  patient  is  encouraged 
to  get  out  of  bed  as  soon  as  possible.  This  operation  is  distinctly 
contra-indicated  in  hard,  small  glands  closely  attached  to  the  fibrous 
capsule. 

Perineal  Prostatectomy  by  Transverse  Incision. — The  pa- 
tient having  been  placed  in  the  exaggerated  dorsal  perineal  position, 


IXJURIEW   AND   DISEASES   OF   THE    PROSTATE. 
Fig.   239. 


759 


Exposure  of  membranous  urethra  after  division  of  recto-uretliralis.     (Young.) 


Fir,.    240. 


Openincr  of  urethra  on  sou nrl   preparatory  to  intrndm-tiiin  of  tractor.      CYountr. ) 


760 


GENITO-UEINAEY   DISEASES   a:ND   SYPHILIS. 


Fig.   241. 


Tractor  in  position,  blades  separated,  prostate  pulled  down,  posterior  surface  exposed.    Incisionis 
in  capsule  on  each  side  of  ejaculatory  ducts.    (Young.) 


INJUKIES   AND   DISEASES   OF   THE    PKOSTATE. 

Fig.   242 


761 


External  enucleation  begun.     (Young.) 


Fig.    243. 


Delivery  of  a  small  median  portion  into  lateral  cavity  by  use  of  finger  instead  of  tractor,    (Young.) 


762 


GENITO-UEINAKY   DISEASES   AND    SYPHILIS. 


Fig.   244. 


Delivery  of  median  portion  into  lateral  cavity.     (Young.) 


INJURIES   AND   DISEASES   OF   THE    PROSTATE. 


763 


by  strongly  flexing  the  thighs  on  the  body,  supplemented  by  securing 
anterior  curvature  of  the  lumbar  spine  by  means  of  a  high  cushion 
placed  beneath  the  sacral  region,  a  staff  is  placed  into  the  bladder  and 


Fig.  245. 


Young's  prostatic  tractor  ;  closed. 


Young's  pros'atic  tractor ;  open. 


the  scrotum  and  penis  are  held  well  up  by  an  assistant,  thus  drawing 
the  bulbous  urethra  well  up  toward  the  symphysis.  The  incision 
should  be  convex,  starting  midway  between  the  anus  9.nd  the  ischial 
tuberosity  of  one  side,  swinging  forward  to  a  point  just  behind  the 


Fig.  247. 


Young's  lobe  forceps. 


perineo-scrotal  junction  and  around  to  a  point  on  the  other  side  cor- 
responding with  its  beginning.  (Fig.  237.)  The  operator  divides  the 
skin  and  superficial  fascia,  the  central  tendon  of  the  perineum,  the  recto- 
urethral  muscle,  and  the  transverse  perinei  muscles  as  well  as  the  tri- 


764 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


angular  ligament.  The  central  tendon  is  divided  close  to  the  bulb, 
thus  freeing  the  anterior  attachment  to  the  sphincter  ani  muscle.  By 
division  of  the  recto-urethral  muscle  the  anterior  support  of  the 
rectum  is  removed,  allowing  the  latter  to  be  held  out  of  the  v^ay  by  a 
broad  retractor.  (Fig.  240.)  The  bulb  is  retracted  forward  and  the 
lateral  edges  of  the  wound  are  drawn  to  the  sides  by  deep  narrow 

Fig.  248. 


Murphy's  hooks. 


retractors,  thus  exposing  the  membranous  urethra  and  the  fibrous 
sheath  of  the  prostate  lying  between  the  two  levator  ani  muscles  and 
partly  covered  by  them.  The  levator  ani  are  pushed  aside  by  blunt 
dissection  and  held  out  of  the  way  by  the  deep  lateral  retractors. 
The  prostatic  sheath  is  then  divided  longitudinally  on  each  side  of  the 
urethra  as  suggested  by  Young,  leaving  between  a  bridge  of  tissue, 
(Fig.  241)  in  which  lie  the  ejaculatory  ducts,  the  sinus  pocularis,  and 


INJURIES   AND   DISEASES   OF    THE    TROSTATE. 


765 


the  prostatic  urethra.     This  incision  should  be  carried  through  the 
outer  fibrous  sheath   and  down  to  the  fibrous  capsule  proper,  and 


Fig.  249. 


Enucleation  of  lobes.    Forceps  in  position.    (Young.) 
Fig.  250. 


Suburethral  methoii  of  enucli'atinu;  median  bar.     (Young.) 

usually  from  one-quarter  to  half  an  inch  in  depth.  The  fibrous  sheath 
over  each  lobe  is  then  partly  separated  from  the  capsule  of  the  gland 
by  the  finger  or  a  blunt  dissector  beginning  at  the  line  of  incision  and 


766 


GENITO-URI]SrAEY   DISEASES   AND   SYPHILIS. 


proceeding  laterally  and  upward  towards  the  bladder.  (Fig.  242.) 
When  separation  is  sufficiently  advanced,  the  long  lateral  retractors 
should  be  placed  within  the  separated  sheath,  thus  giving  the  freer 
exposure  and  making  more  accessible  the  prostate  itself.  At  times, 
by  means  of  tenacula  and  forceps,  enucleation  can  be  rapidly  com- 
pleted. Usually,  it  is  necessary  to  bring  the  gland  still  further  in 
reach,  and  this  may  be  best  accomplished  by  Young's  tractor.  This 
instrument  is  introduced  through  an  incision  into  the  prostatic  urethra 
as  near  the  apex  of  the  gland  as  possible.     (Fig.  241.)     This  incision 


Fig.  251. 


Division  of  lateral  wall  of  urethra  to  arjo\v  extraction  of  large  calculus  through  lateral  cavity. 

(Young.) 

should  be  sufficiently  large  to  introduce  the  index-finger,  which,  by 
dilating  the  prostate,  is  passed  into  the  bladder.  By  means  of  the 
finger  the  deeper  parts  of  the  gland  may  be  made  so  accessible  that 
complete  removal  is  easily  accomplished.  (Fig.  243.)  If,  however, 
the  mass  is  still  inaccessible.  Young's  prostatic  tractor  is  introduced 
closed,  its  blades  are  then  opened,  and  the  gland  is  delivered  into  the 
wound  by  upward  traction  made  by  an  assistant.  (Fig.  244.)  It 
should  be  remembered  that  the  fibrous  sheath  or  false  capsule  of 
the  prostate  may  exhibit  in  itself  a  line  of  cleavage  between  its 
layers,  and  if  the  operator  be  misled  by  this  into  the  belief  that  he 


INJUKTES   AND    DISEASES   OF   THE    PROSTATE. 


767 


has  reached  the  true  capsule,  he  is  in  grave  danger  not  only  of 
producing  lesions  of  the  bladder  and  rectum,  but  of  causing  severe 
hemorrhage.  If  the  true  capsule  is  penetrated  and  separation  is 
begun  in  the  gland  substance,  imperfect  removal  will  result,  the 
gland  coming  away  piecemeal.  Where  morcellement — i.e.,  piece- 
meal destruction — is  necessary,  it  is  best  accomplished  by  Ferguson's 
forceps.     Special  care  is  taken  to  avoid  wounding  the  urethra,  which 


Perineal  drainage  after  prostatectomy.     (Ferguson.) 

is  sufficiently  outlined  either  by  a  sound  or  the  staff  of  the  tractor. 
A  double  tube  for  continuous  irrigation  is  introduced  into  the  bladder, 
the  borders  of  the  levator  ani  muscles  are  brought  together  by  chromic 
catgut  sutures,  and  the  skin  wound  is  closed  except  for  the  space 
required  for  drainage.  Continuous  irrigation  is  kept  up  for  twelve 
hours,  when  the  tubes  are  removed,  unless  there  has  been  severe 
cystitis.  The  patient  is  put  in  a  sitting  posture  as  soon  as  possible, 
usually  in  two  or  three  days. 


768  GENITO-UKIlSrARY   DISEASES   AND   SYPHILIS. 

The  Results  of  Prostatectomy. — The  removal  of  the  prostate, 
if  skilfully  conducted  and  in  properly  selected  cases,  affords  a  per- 
manent cure  of  urinary  retention  in  the  great  majority  of  cases,  and, 
moreover,  produces  a  peculiarly  regenerating  effect  upon  the  cases 
subject  to  operation.  Enucleation  may  be  extremely  easy,  being 
accomplished  m  a  few  minutes  or  may  be  impossible  of  accomplish- 
ment in  the  hands  of  the  most  skilled.  Thus,  Albarran  notes  that 
enucleation  v^as  easy  in  twenty-nine  cases,  difficult  in  seven,  and 
impracticable  in  three. 

The  mortality  of  the  operation  varies  somewhat  according  to  the 
procedure  adopted. 

Transvesical  prostatectomy  is  generally  regarded  as  more  lethal 
than  the  perineal  operation.  Watson  gives  a  mortality  of  eleven  and 
three-tenths  per  cent.,  almost  double  that  of  the  perineal  operation. 
Escat  notes  thirty-one  deaths  in  one  hundred  and  sixty-four  cases 
(eighteen  per  cent.).  Freyer,  whose  statistics  are  among  the  best, 
gives  a  mortality  of  ten  and  ninety-five  one  hundredths  per  cent. 
Hemorrhage,  shock,  uraemia,  and  infection  were  the  prominent  causes 
of  immediate  mortality.  Pelvic  abscess,  calculus  formation,  reopen- 
ing of  the  suprapubic  wound,  and  stricture  were  noted  as  remote 
sequelae. 

Total  perineal  prostatectomy  gives  a  mortality  of  six  per  cent. 
(Proust,  seven  hundred  and  twenty-four  cases  ;  Watson,  five  hundred 
and  thirty  cases),  and  from  the  statistics  of  individual  operators  of 
from  three  to  six  per  cent.,  though  Rochet  records  a  mortality  of 
eleven  and  three-tenths  per  cent.  Complications  which  are  compara- 
tively frequent  are  orcho-epididymitis,  fistula,  incontinence  of  urine, 
stricture,  and  pulmonary  embolus.  There  is  sometimes  trouble  in 
defecation,  either  incontinence  or  coprostasis.  Petit  reports  twelve 
cases  of  orcho-epididymitis  in  thirty-eight  cases,  and  Rafm  eight  in 
twenty-four  cases.  It  is  sometimes  double,  and  is  not  absolutely 
prevented  by  ligature  of  the  vas  deferens. 

Watson  notes  urethrorectal  fistulae  in  two  and  seven-tenths  per 
cent,  of  five  hundred  and  thirty  cases.  Escat  notes  in  three  hun- 
dred and  eighty-two  cases  a  percentage  of  fistulae  nearly  twice  as 
great.  This  constitutes  a  serious,  at  times  a  fatal,  sequel  to  operation. 
Incontinence  following  perineal  prostatectomy  is  usually  transitory, 
though  its  persistence  has  been  observed  for  two  years. 

Watson  records  pulmonary  complications,  such  as  embolus,  pneu- 
monia, and  congestion,  in  seventeen  per  cent,  of  cases. 

Impotence  is  the  almost  invariable  sequel  of  perineal  prostatectomy. 


DISEASES   AND   INJURIES   OF   THE   PROSTATE.  7^9 

Castration  and  Vasectomy. — One  of  us  (White)  {Annals  of 
Surgery,  Dec,  1904)  has  recently  summarized  as  follows  the  history  of 
these  operations  and  his  personal  views  in  regard  to  them :  Probably 
most  surgeons  would  to-day  dismiss  castration  and  vasectomy  from 
consideration  as  summarily  as  I  have  rejected  interstitial  injection  or 
transrectal  galvanism.  It  may  be  that  they  are  entirely  right.  It  was 
in  an  address  before  the  American  Medical  Association,  1893,  that  I 
first  suggested  castration  as  a  possibility  in  the  treatment  of  prostatic 
hypertrophy.  Ramm,  of  Norway,  appears  to  have  had  the  same  idea 
at  about  the  same  time,  but  to  have  published  nothing  until  later. 
Doubtless  others  had  thought  of  it  more  or  less  vaguely,  but  no  one 
seems  to  have  tested  its  value  experimentally  as  I  had  done  pre- 
vious to  laying  it  before  the  profession.  I  said  towards  the  end 
of  the  paper :  "  I  have  one  further  thought  to  mention  to  this  Asso- 
ciation, although  I  do  so  with  a  reluctance  born  of  the  fear  of  being 
considered  illogical  or  impractical,  or  perhaps  both."  I  then 
went  on  to  recall  the  well-known  theory  as  to  the  analogy  between 
uterine  fibromyomata  and  prostatic  overgrowth,  the  effect  of  oopho- 
rectomy on  the  former,  the  testimony  as  to  the  infantile  character  of 
the  prostate  in  the  eunuchs,  the  observations  of  John  Hunter  and 
Griffiths  upon  the  prostates  of  the  mole,  the  hedgehog,  and  the  bull, 
and  finally  described  the  results  of  the  experimental  castration  of  dogs 
(Kirby) — with  control  experiments — in  the  following  words:  "These 
results,  which  I  believe  may  be  relied  upon,  place  beyond  all  perad- 
venture  the  influence  of  castration  (in  the  dog  at  least)  upon  the  con- 
dition of  the  prostate,  and  show  clearly  that  the  operation  is  followed 
invariably,  and  with  a  promptness  which  I  must  confess  was  to  me 
surprising,  by  atrophy  first  of  the  glandular  and  then  of  the  muscular 
elements,  and  by  a  coincident  reduction  in  both  bulk  and  weight." 
After  discussing  the  possibilty  of  making  these  facts  a  basis  for  the 
employment  of  castration  in  prostatic  hypertrophy,  I  said :  "  I  do  not 
desire  to  be  understood  as  insisting  upon  the  truth  or  even  upon  the 
probability  of  the  above  hypothesis.  I  have  simply,  with  much  hesi- 
tation, determined  to  follow  out  publicly  a  line  of  thought  that  had 
occupied  my  mind  at  odd  times,  and  to  submit  it  to  your  criticism  ; " 
and  added :  "  I  might  admit,  finally,  that  I  have  not  had  the  courage 
of  my  convictions,  and  have  never  seriously  sought  to  recommend 
the  operation,  but  it  would  be  truer  to  say  that  I  have  as  yet  no 
detinite  convictions,  and  that  I  am  simply  seeking  enough  light  upon 
the  subject  to  convince  me  either  that  it  is  worth  pursuing  further, 

49 


770  GENITO-URINARi:    DISEASES   AND   SYPHILIS. 

or,  on  the  other  hand,  that  it  offers  no  possibility  of  practical  use- 
fulness." 

Even  with  so  cautious  a  presentation  of  the  subject,  however,  the 
operation  was  taken  up  all  over  the  world  with  great  rapidity,  and 
large  numbers  of  patients  were  subjected  to  it,  some  of  them,  as  the 
reports  show,  already  moribund.  Many  cases  were  operated  upon 
and  the  immediate  results  published  before  I  had  myself  found  what  I 
regarded  as  a  case  suitable  for  this  procedure. 

I  had  spoken  of  the  operation  as  one  "  with  a  low  mortality,"  and 
so  conservative  a  surgeon  as  Lord  Lister,  in  commenting  on  my  paper, 
remarked  that  I  should  have  said  "  with  no  mortality."  I  was  dis- 
appointed to  find  that  a  very  considerable  mortality  was  reported.  It 
was  true  that  the  majority  of  the  deaths  were  obviously  in  spite  of, 
not  because  of,  the  operation.  Still,  the  death-rate  was  larger  than 
any  one  had  anticipated.  Two  years  later  (July,  1895)  I  was  able  to 
gather  from  surgical  literature  and  through  correspondence  a  series 
of  one  hundred  and  eleven  cases  that  had  been  operated  upon.  The 
deaths  were  twenty,  thirteen  of  which  I  thought  should  be  excluded  in 
an  attempt  to  arrive  at  the  legitimate  mortality,  as  they  had  occurred 
in  cases  that  were  obviously  at  the  point  of  death  when  operated 
upon.  Even  with  this  exclusion — which  was  not  assented  to  by  the 
critics  of  the  operation — the  remaining  mortality  of  seven  per  cent, 
was  greater  than  I  had  anticipated. 

A  glance  at  that  paper  with  its  table  of  cases  will  show  appar- 
ently (according  to  the  reports  of  surgeons  from  all  countries  in  the 
world)  that  in  about  eighty-five  per  cent,  of  cases  such  diminution 
in  size  of  the  prostate  had  rapidly  followed  the  operation  that  it 
was  thought  to  be  analogous  to,  or  identical  with,  the  atrophy  I  had 
experimentally  shown  to  occur  in  dogs ;  that  long-standing  cystitis 
had  disappeared  or  greatly  lessened  in  more  than  half  the  cases ; 
that  distinct  amelioration  of  the  most  troublesome  symptoms  had 
occurred  in  over  eighty  per  cent,  and  a  return  to  local  conditions  not 
very  far  removed  from  normal  in  forty-six  per  cent,  of  those  operated 
upon. 

At  this  time  I  felt  hopeful  as  to  the  future  of  the  operation,  and 
defended  it  to  the  best  of  my  ability,  on  the  basis  of  these  clinical 
reports  of  actual  cases.  By  the  end  of  1896  I  said  that  I  would  be 
quite  content  if  nothing  better  could  ever  be  said  of  the  operation  than 
Dr.  Arthur  Cabot  (who  had  been  a  keen  and  thoughtful  critic  from  the 
beginning)  said  would  be  justified  by  the  then  existing  statistics  if 
further  experience  confirmed  them,  viz.,  "  We  shall  be  able  to  express 
the  facts  thus  to  our  inquiring  patients  :  You  have  eight  chances  in  ten 


DISEASES   AND   INJURIES   OF    THE   PROSTATE.  771 

of  getting  through  the  operation  all  right,  and  if  you  are  successful  in 
this,  you  have  again  eight  chances  in  ten,  or  a  little  better,  of  getting 
very  substantial  relief  from  your  urinary  difficulties." 

In  1900,  Dr.  Alfred  Wood  published  a  collection  of  one  hundred 
and  fifty-nine  cases  of  castration,  and  one  hundred  and  ninety-three 
cases  of  vasectomy,  none  of  which  had  been  included  in  my  table  of 
1895,  or  in  Cabot's  table  of  1896.  The  reported  results  of  the  castra- 
tions showed  thirteen  deaths  (a  little  over  eight  per  cent,  of  mortality), 
and  with  some  variations  corresponded  approximately  to  the  results 
shown  in  the  earliest  table.  In  the  vasectomies  the  mortality  was 
six  and  seven-tenths  per  cent.,  and  in  sixty-seven  per  cent,  some  form 
of  general  improvement  was  noted. 

In  the  same  year  (1900)  Mr.  Reginald  Harrison  reported  more  than 
one  hundred  cases  of  vasectomy,  and  said  that  he  had  been  able  to 
observe  "benefit  of  some  kind  and  in  some  degree  in  almost  every 
case,  although  the  accompanying  conditions  often  prevented  anything 
like  a  cure." 

In  1902,  Rovsing  reported  forty  cases  of  vasectomy,  of  which 
twenty-seven  were  cured,  nine  relieved,  and  four  unimproved.  There 
were  no  deaths.  He  adds :  "  I  should  under  no  circumstances  feel 
myself  justified  in  undertaking  the  total  extirpation  of  the  prostate  in 
a  patient  in  whom  I  had  not  done  a  vasectomy,  which  in  many  cases 
gives  such  extraordinary  relief." 

During  the  decade  during  which  this  evidence  has  been  accumu- 
lating I  have  in  my  own  practice — including  both  private  and  hospital 
patients — found  but  fifteen  caSes  in  which  I  thought  castration  justi- 
fiable, and  thirty-seven  cases  in  which  I  have  performed  vasectomy. 
I  mention  these  figures  merely  to  indicate  that  I  have  tried  to  preserve 
the  conservatism  with  which  I  suggested  the  operation  originally. 

My  present  opinion  is  that  castration  and  vasectomy  are  likely  to 
occupy  a  more  and  more  restricted  field  in  the  treatment  of  prostatic 
hypertrophy.  In  properly  selected  cases  I  still  think  that  they  are 
likely  to  have  a  low  mortality,  and  that  when  fully  successful  they 
secure  a  return  to  a  condition  more  closely  resembling  the  normal 
than  most  of  the  other  operations  looking  towards  a  radical  cure  of 
the  hypertrophied  prostate.  Although  in  the  several  hundreds  of  re- 
ported cases  the  outcome  seemed  in  the  majority  of  instances  to  be 
satisfactory  to  the  operators,  these  procedures  have  been  gradually 
given  up  in  favor  of  various  others  more  recently  advocated.  The 
uncertainty  of  their  results,  both  immediate  and  remote ;  the  fact  that 
they  are  not  free  from  danger;  and,  so  far  as  castration  is  concerned, 
the  strong  and  not  unreasonable  sentimental  objections  to  it,  combine 


772  GENITO-URINAKY    DISEASES   AND   SYPHILIS. 

to  render  their  final  status  in  the  treatment  of  prostatic  hypertrophy  a 
matter  of  doubt.  It  may  be  that  a  better  classification  of  prostatics 
in  accordance  with  their  clinical  history  will  resolve  this  doubt. 

In  the  meanwhile,  without  the  least  disposition  to  urge  these  opera- 
tions upon  the  profession,  or  to  claim  anything  for  them  which  facts 
do  not  justify,  I  would  suggest  that  they  still  merit  at  least  occasional 
consideration ;  that  not  all  of  the  published  reports  of  successes  can 
be  inaccurate  or  misleading ;  that  such  testimony  as  Harrison's  or 
Rovsing's  should  not  lightly  be  ignored ;  and  that  it  is  quite  possible 
that  there  may  still  be  a  definite  field  of  usefulness  for  these  pro- 
cedures, although  I  now  believe  that  it  will  be  much  more  limited  than 
I  at  one  time  thought  it  would  be. 

My  opinion  as  to  the  greatly — and  justly — increased  limitations  of 
these  operations  in  the  future  is  much  influenced  by  the  improvements 
in  the  methods  of  performing  prostatectomy. 

Cases  of  death  with  precedent  mental  symptoms,  described  as  mania, 
acute  mania,  etc.,  are  only  such  as  every  surgeon  is  familiar  with  in  a 
certain  proportion  of  operations  done  upon  aged  persons,  whose  men- 
tal equilibrium  is  easily  disturbed,  and  can  have  no  bearing  upon  the 
question  of  later  mental  changes  as  the  result  of  castration.  AVith 
greater  accuracy  we  should  probably  classify  the  large  majority  of 
them  as  ursemia  and  some  of  the  remainder  as  traumatic  delirium. 
Chnical  evidence  leads  to  the  belief  that  the  removal  of  the  testicles 
from  persons  who  have  reached  full  adult  life,  and  a  fortiori  from 
very  aged  persons,  has  no  ejEfect  upon  the  mental  functions  or  upon 
the  general  physical  characteristics.  Impotence  will  undoubtedly  be 
caused  in  the  majority  of  cases,  but  even  this  is  not  immediate  or 
inevitable. 

Castration. — The  operation  of  castration  has  been  described 
already.  The  patients  on  wiiom  it  is  performed  for  the  rehef  of 
enlarged  prostates  are  old,  feeble,  vulnerable,  and  little  fitted  to  react 
from  any  prolonged  surgical  intervention.  Ether  should  be  given  to 
the  first  stage.  An  assistant  then  grasps  the  scrotum  from  behind, 
pressing  the  testicle  forward  and  making  the  overlying  skin  tense. 
The  surgeon  makes  a  three-inch  incision,  through  which  the  testicle 
is  squeezed  by  the  pressure  of  the  assistant's  hand.  The  gland  is 
grasped,  pulled  well  forward,  the  ligament  attaching  the  base  of  the 
testicle  and  the  epididymis  to  the  scrotum  behind  is  divided  with  the 
scissors  or  knife,  the  cord  is  pulled  well  down,  transfixed,  ligatured, 
and  divided,  the  lumen  of  the  vas  is  touched  with  a  crystal  of  pure 
carbolic  acid,  and  the  parietal  wound  is  closed  by  two  or  three  silk 
or  horse-hair  sutures,  no  drainage  being  employed.     Not  more  than 


INJUKIES   AND   DISEASES   OF    THE    PKOSTATE.  773 

two  or  three  blood-vessels  need  be  secured,  and  both  testicles  should 
be  removed  in  less  than  five  minutes.  The  wounds  are  dressed  with 
an  abundance  of  loosely  crumpled  sterile  gauze,  secured  in  place  by 
a  crossed  of  the  perineum  bandage. 

Vasectomy. — The  operation  possesses  the  advantages  of  not  re- 
quiring ether  for  its  performance,  of  not  exciting  the  opposition  of  the 
patient,  and  of  producing  no  appreciable  deformity.  It  is  easily  and 
quickly  done,  and  does  not  cause  shock.  The  vas  is  usually  most  ac- 
cessible through  the  posterior  surface  of  the  scrotum.  It  is  isolated 
from  its  surrounding  veins,  and  is  held  in  place  close  beneath  the  skin, 
which  is  stretched  tightly  over  it  by  the  two  hands  of  an  assistant,  the 
thumbs  and  forefingers  making  firm  pressure  and  holding  the  vas 
away  from  the  other  structures  of  the  cord.  The  skin  overlying  the 
vas  is  then  infiltrated  by  Schleich's  solution  of  cocaine  and  is  di- 
vided;  the  fibrous  tissue  overlying  the  vas  is  cut  through,  the  vas 
itself  is  isolated  and  hooked  out  with  a  grooved  director,  is  freed  for 
an  inch,  and  a  ligature  applied  above  and  below,  and  the  portion 
lying  between  the  ligatures  is  removed.  The  wound  is  closed  by  a 
stitch,  and  the  testicle  is  enveloped  in  sterile  gauze  and  supported  by 
a  crossed  of  the  perineum  bandage. 

ATROPHY   OF   THE   PROSTATE. 

In  exhausting  diseases  accompanied  by  general  wasting  of  the  en- 
tire body  marked  atrophy  of  the  prostate  may  occur.  Thus,  Thomp- 
son noted  one  case  in  which  the  gland  weighed  less  than  one  drachm. 
Extreme  old  age  is  usually  accompanied  by  wasting  of  the  prostate ; 
mechanical  pressure,  as  from  extravesical  tumor  or  prolonged  dis- 
tention of  the  bladder,  may  produce  the  same  effect.  The  gland  may 
also  be  partly  or  completely  destroyed  by  abscess-formation  followed 
by  cicatricial  contraction  and  by  sclerosis  secondary  to  chronic  in- 
flammation. In  certain  cases  the  prostate  is  congenitally  atrophied, 
this  condition  being  generally  associated  with  other  malformations. 
Castration,  especially  if  performed  in  early  life,  is  always  followed  by 
prostatic  atrophy,  and  masturbation,  if  begun  early,  and  if  excessive 
and  long  continued,  may  result  in  a  similar  condition.  Symptoms  of 
atrophy  are  practically  wanting. 

The  diagnosis  is  founded  upon  rectal  examination. 

Treatment  is  unavailing. 

PROSTATIC   CALCULI. 
Thompson  has  shown  that  the  corpora  amylacea  are  so  constantly 
found  in  the  prostate  that  their  presence  can  scarcely  be  considered 


774  GENITO-URINAEY   DISEASES    AND   SYPHILIS. 

abnormal.  In  youth  these  bodies  are  usually  microscopic  in  size. 
Later  in  life  they  become  larger,  so  that  they  are  readily  seen  by  the 
naked  eye.  The  name  corpora  amylacea  is  given  to  them  because  they 
exhibit  a  granular  nucleus,  probably  made  up  of  degenerated  epithelial 
cells  and  inspissated  mucus,  about  which  are  formed  concentric  layers 
composed  of  an  albuminoid  substance  the  nature  of  which  is  not  rightly 
understood,  and  presenting  the  microscopic  appearance  of  starch  cells. 
When  the  corpora  amylacea  are  small  they  occasion  no  symptoms : 
as  they  grow  larger  they  act  as  foreign  bodies,  exciting  inflammation, 
and  have  deposited  in  and  upon  them  the  salts  of  lime,  calculi  being 
thus  formed.  The  calculi  may  he  separately,  each  in  its  own  pouch, 
or  many  of  them  may  be  placed  in  a  common  pouch,  often  adherent 
to  one  another.  In  color  they  are  brown  or  black,  with  a  smooth 
polished  surface,  exhibiting  facets  when  a  number  of  calcuh  are  placed 
together  in  a  single  pocket.  They  are  made  up  of  calcium  phos- 
phate, calcium  carbonate,  and  organic  matter,  and  are  commonly 
found  below  the  urethra,  particularly  in  the  region  of  the  verumon- 
tanum.  If  by  ulceration  the  cavity  in  which  they  lie  opens  into  the 
urethra,  and  the  urine  has  access  to  them,  its  salts  will  be  deposited 
upon  them,  causing  rapid  growth,  abscess-formation,  and  ulceration, 
usually  in  the  direction  of  the  urethra,  sometimes  backward  towards 
the  bladder,  or  into  the  rectum  or  the  perineum. 

Prostatic  calculi  may  originate  in  the  substance  of  the  gland  as 
just  described,  may  come  from  the  bladder  or  the  urethra,  or  may  be 
deposited  from  the  urine  in  suppurating  prostatic  pouches. 

Symptoms. — Until  prostatic  calculi  of  glandular  formation  open  into 
the  urethra,  symptoms  are  usually  wanting,  the  condition  not  being 
generally  recognized  until  it  is  shown  by  post-mortem  examination  or 
operation  performed  for  some  other  pathological  condition.  When 
the  calculi  begin  to  grow  from  deposition  of  urinary  salts,  the  symp- 
toms of  posterior  urethritis  or  of  chronic  prostatitis  develop. 

Diagnosis  is  founded  on  rectal  palpation  and  urethral  examination. 
These  calcuh,  if  of  considerable  size,  can  generally  be  felt  by  the 
finger  introduced  into  the  rectum.  A  metal  catheter  will  give  a 
grating  sound  as  it  is  introduced  into  the  prostatic  urethra ;  urethro- 
scopic  examination  will  bring  the  concretions  directly  into  view. 

Treatment. — It  is  sometimes  possible  to  remove  calculi  from  a 
suppurating  prostate  by  the  straight  or  slightly  curved  urethral  forceps. 
We  have  removed  ten  from  one  patient  in  this  manner,  and  the 
patient  has  remained  perfectly  weh.  A  perineal  urethrotomy  affords 
the  safest  and  best  route  for  thorough  removal  of  these  concretions. 
The  median  perineal   incision  gives  enough  room.     Exceptionally. 


INJURIES   AND   DISEASES   OF   THE    PROSTATE.  775 

when  it  is  necessary  to  make  a  careful  exploration  of  the  entire  pros- 
tate, the  semilunar  incision  in  front  of  the  anus  is  required,  the  anus 
with  its  sphincter  and  the  rectum  being  carried  backward,  the  pros- 
tate exposed,  and  the  calculi  freed  and  removed  through  the  incision. 
For  the  very  small  calculi  which  pass  spontaneously  no  treatment  is 
necessary  other  than  avoidance  of  all  causes  of  prostatic  congestion, 
as  constipation  and  alcoholic  or  sexual  excess.  When  in  consequence 
of  prostatic  calculi  there  are  harassing  pains,  undue  frequency  of 
urination,  retention  of  urine,  or  cystitis,  we  believe  that  surgical  inter- 
vention is  imperatively  indicated. 

MALIGNANT   TUMORS    OF   THE    PROSTATE. 

Oarcinoraa,  when  it  occurs  as  a  primary  tumor,  is  usually  ob- 
served after  the  fiftieth  year  of  life.  The  majority  of  the  tumors  are 
carcinomatous.  Oraison,  of  fifty-five  malignant  prostatic  neoplasms, 
notes  that  forty-eight  were  carcinomatous  and  seven  sarcomatous,  the 
latter  occurring  in  young  subjects. 

Praust  and  Vian  state  that  sarcoma  is  characterized  by  extreme  ra- 
pidity of  development.  In  young  people  retention  of  urine  accompa- 
nied by  rapidly  growing  prostatic  tumor  are  the  characteristic  signs. 
In  old  men  the  differential  diagnosis  may  be  quite  impossible  without 
microscopic  examination.    The  induration,  however,  is  less  marked. 

Albarran  and  Halle  noted  fourteen  epitheliomatous  prostates  in  a 
hundred  subjects  supposed  before  autopsy  to  be  suffering' from  simple 
enlargement  and  thus  corroborate  the  tindings  of  Greene  and  Brooks. 

Hallopeau  holds  that  malignant  infiltrations  are  found  once  in  every 
ten  hypertrophies.  In  infants  and  young  adults  they  are  always  sar- 
comas. In  old  men  they  are  usually  epitheliomas.  They  develop 
usually  in  the  upper  posterior  part  of  the  gland  invaded. 

Metastases  may  occur  early  particularly  in  the  bones,  the  lumbar 
vertebrae  being  those  of  predilection.  In  about  half  the  cases  there 
is  ultimately  local  extension,  and  glandular  involvement  takes  place  in 
fifty  per  cent.  (Kaufmann)  of  cases,  the  iliac  and  inguinal  being  those 
chiefly  affected. 

Symptoms. — These  at  the  time  when  operation  may  be  curative  are 
identical  with  the  symptoms  due  to  the  commonly  associated  prostatic 
hypertrophy.  On  rectal  examination  tenderness  may  be  elicited,  but 
most  characteristic  and  significant  is  the  wooden  hardness  of  the  gland, 
and  the  backward  extension  along  the  seminal  vesicles. 

When  the  disease  is  well  advanced,  distinct  bosses  or  involvment 
of  the  periprostatic  tissue,  extensive  infiltration  of  the  pelvic  nodes, 
fixation  of  the  rectal  mucosa  with  shot-like  nodules  found  in  it,  heema- 


776  GENITO-UKINAEY  DISEASES  AND  SYPHILIS. 

turia,  especially  initial  and  terminal,  and  cachexia  sufficiently  denote 
both  the  diagnosis  and  the  inadequacy  of  any  surgical  treatment. 

Diagnosis. — This  is  most  often  suggested  at  an  early  stage  by  the 
board-like  induration  of  the  prostate  which  before  the  development  of 
retention  causes  an  unusual  amount  of  pain  uninfluenced  by  the  act 
of  micturition.  Later,  initial  and  terminal  haematuria  and  rapid,  often 
nodular,  enlargement  are  characteristic. 

Treatment. — Operation,  if  j)erformed  early,  before  metastases  have 
developed  or  the  disease  has  invaded  the  surrounding  structures,  gives 
a  large  percentage  of  cures.  Oraison  reports  twenty-three  cases  ;  four 
died  from  operation,  ten  remained  free  from  recurrence  for  over  four 
years,  and  three  suffered  from  recurrence.  The  remainder  recovered, 
but  their  subsequent  histories  could  not  be  obtained.  (Hawley.)  The 
disease  may  remain  strictly  localized  for  a  long  period.  Total  prosta- 
tectomy, including  the  prostatic  urethra,  seems  the  method  of  choice. 
When  the  paraprostatic  tissues  are  involved,  the  pelvic  lymph  nodes 
are  infiltrated,  or  bone  metastases  have  developed,  radical  operation  is 
futile.  Under  such  circumstances  effort  is  directed  towards  relief  of 
the  retention  of  urine,  the  alleviation  of  the  accompanying  cystitis, 
and  mitigation  of  the  pain.  Retention  of  urine  should  be  relieved  by 
intermittent  or  continuous  catheterization.  Should  this  cause  severe 
bleeding,  suprapubic  incision  and  drainage  are  indicated.  The  cystitis 
is  best  treated  by  suprapubic  drainage  and  antiseptic  irrigations.  The 
pain  is  controlled  by  opium  and  morphine  administered  by  the  rectum 
or  hypodermically. 

Cysts  of  the  Prostate. — Cysts  of  the  prostate  are  either  hyda- 
tid or  retention.  The  hydatid  cysts  are  so  extremely  rare  that  symp- 
tomatology based  on  clinical  experience  can  scarcely  be  formulated. 
The  symptoms  would  naturally  be  dependent  on  interference  with 
micturition  or  defecation,  and  pain. 

The  detection  of  a  fluctuating,  non-inflammatory  tumor  would 
lead  to  a  diagnosis. 

Retention  cysts  are  frequently  associated  with  hypertrophied  pros- 
tates, but  in  any  case  are  rare.  Usually  they  are  due  to  obstruction 
of  the  prostatic  follicles.  Exceptionally  the  cyst  may  be  due  to 
narrowing  or  obliteration  of  the  opening  of  the  utricle.  In  this  case 
interference  with  micturition  might  readily  occur.  Enghsch  found  five 
examples  of  this  affection  out  of  seventy  post-mortem  examinations 
of  newly  born  children. 

The  treatment  is  puncture  through  the  perineum,  evacuation,  and 
drainage. 


CHAPTER   XXI. 

SEXUAL    WEAKNESS    AND    STERILITY. 

The  term  impotence  implies  a  lack  of  ability  to  perform  the  sexual 
act.  It  is  not  necessarily  associated  with  sterility,  nor  is  a  sterile  per- 
son necessarily  impotent.  Thus,  patients  whose  ejaculations  are  pre- 
mature and  whose  erections  are  feeble  or  wanting,  though  unable  to 
have  sexual  relations,  may  discharge  semen  swarming  with  living 
spermatozoa ;  while  those  who  are  particularly  vigorous  in  sexual 
congress  may  have  no  emissions,  or  may  emit  fluid  entirely  devoid  of 
living  spermatozoa. 

Impotence  in  the  male  may  be  due  to  congenital  or  acquired  de- 
formity or  to  feebleness  or  deficiency  in  erection. 

Mechanism  of  Erection. — In  the  ordinary  condition  of  the  penis 
the  muscular  fibres  lining  the  trabeculee  are  in  a  condition  of  tonic 
contraction :  hence  the  spaces  are  obliterated.  Moreover,  the  arteries 
are  so  contracted  that  no  more  blood  is  furnished  than  is  sufficient 
for  the  nourishment  of  the  parts :  hence  circulation  is  carried  on  as 
in  other  parts  of  the  body.  When  the  impulse  is  sent  out  from  the 
erection  centre  the  arteries  dilate  and  the  muscular  structure  of  the 
erectile  tissue  relaxes :  hence  there  are  provided  an  increased  blood- 
supply  and  spaces  for  its  accumulation.  At  the  same  time,  as  a  result 
of  muscular  contraction,  the  veins  carrying  the  return  blood  are 
pressed  upon  and  congestion  is  thus  increased.  As  a  result  the  erec- 
tile tissue  becomes  turgid,  and  this  in  itself  adds  to  the  tendency  to 
engorgement,  since  the  fibrous  investment  of  the  penis  is  put  upon 
the  stretch,  and  thus  the  venous  return  is  materially  interfered  with. 
As  the  penis  becomes  tense  and  rigid  it  is  mechanically  carried  up- 
ward to  an  elevation  of  about  forty-five  degrees  by  the  action  of  the 
suspensory  hgament,  though  both  the  erector  penis  and  the  accele- 
rator urinse,  by  drawing  downward  and  backward  upon  the  organ 
behind  the  position  of  this  ligament,  assist  in  maintaining  this  position. 
Erection  is  finally  completed  by  the  active  participation  of  the  perineal 
group  of  muscles.  The  erector  penis,  the  accelerator  uringe,  the  trans- 
versus  perinei,  and  the  compressor  urethrae  by  tonic  contraction  with 
clonic  accentuations,  materially  increase  the  venous  congestion. 

With  all  the  factors  described  in  harmonious  action,  the  penis 

777 


778  GENITO-UKINARY    DISEASES   AND   SYPHILIS. 

becomes  fully  erect ;  its  hardness  is  dependent  upon  the  amount  of 
engorgement  and  the  density  of  its  fibrous  investment ;  the  spongy 
body  and  the  glans  are  never  as  hard  as  the  cavernous  bodies. 

As  the  result  of  sexual  excitement  coincident  with  erection,  the 
testicles  are  drawn  close  to  the  abdomen  by  contraction  of  the  dartos 
and  of  the  muscular  fibres  of  the  cord.  It  is  probable  that  the  sper- 
matozoa which  fill  the  epididymis  are  rapidly  carried  by  the  peristaltic 
action  of  the  muscular  coat  of  this  tube  and  of  the  vas  to  the  ampulla, 
from  which  dilatation,  the  ejaculatory  duct  being  patulous,  sperma- 
tozoa are  driven  into  the  prostatic  urethra.  In  the  mean  time,  as  a 
result  of  the  active  congestion,  the  mucous  glands  and  follicles  of  the 
urethra  have  been  secreting  a  clear,  slightly  alkaline,  viscid  mucus,  the 
possible  purpose  of  which  may  be  the  neutrahzation  of  any  acid  urine 
which  may  remain  in  contact  with  this  tube.  At  the  time  of  orgasm 
the  muscles  of  the  -prostate  vigorously  contract  as  the  compressor 
urethrse  muscle  becomes  relaxed :  thus  not  only  the  spermatozoa 
and  the  contents  of  the  seminal  vesicles,  but  also  the  prostatic  secre- 
tion, are  driven  forward  into  the  bulbous  urethra,  being  prevented 
from  going  back  into  the  bladder  by  the  congestion  of  the  erectile 
tissue  of  the  verumontanum  and  also  probably  by  contraction  of  the 
internal  sphincter  of  the  bladder.  Once  in  the  bulbous  urethra,  the 
semen  is  driven  forward  by  contraction  of  the  whole  perineal  group, 
aided  by  the  muscular, fibres  of  the  urethra. 

The  semen  is  a  composite  fluid,  made  up  of  the  secretion  of  the 
testicles,  seminal  vesicles,  prostate  glands,  Cowper's  glands,  and  the 
urethral  crypts  and  folhcles.  It  is  a  gray  fluid,  becoming  gelatinous  on 
ejaculation.  If  allowed  to  stand  it  becomes  thin,  and  there  settles 
from  it  an  opaque  deposit,  made  up  of  spermatozoa,  over  which  lies 
a  layer  of  about  ec|ual  thickness  of  gray,  translucent  liquid.  The 
characteristic  odor  of  semen  is  probably  given  to  it  by  the  prostatic 
secretion.  It  resembles  that  of  a  raw  potato.  Spermatozoa  at  the 
time  of  ejaculation  and  for  about  twenty-four  hours  afterwards,  if 
evaporation  is  prevented,  should  be  in  active  motion.  When  the 
semen  is  deposited  in  the  female  genital  tract,  spermatozoa  live  for 
many  days.  After  standing  for  two  or  three  days,  healthy  semen 
deposits  the  spermatic  crystals.  The  amount  discharged  at  one 
orgasm  is  from  one  to  two  drachms,  though  this  quantity  is  subject 
to  marked  variations. 

The  nerve-centres  for  erection  and  ejaculation  are  situated  in  the 
lumbar  cord,  the  fibres  passing  outward  from  the  erector  centre 
being  termed  nervi  erigentes. 

The  erector  centre  may  be  stimulated  by  reflexes  from  the  geni- 


SEXUAL   WEAKNESS   AND   STEEILITY.  779 

talia  or  from  regions  associated  by  nerve  anastomosis,  by  the  direct 
action  of  the  brain,  or  by  injuries  or  diseases  of  the  spinal  cord. 
Familiar  examples  of  erection  from  reflex  action  are  afforded  by  the 
morning  priapism  incident  to  a  full  bladder ;  by  the  continued  erec- 
tion sometimes  associated  with  prostatic  calculus  or  with  inflammation 
of  the  posterior  urethra ;  and  by  the  tendency  to  local  congestion 
exhibited  with  balanoposthitis.  The  effect  of  sights,  sounds,  odors, 
or  mental  conceptions  upon  the  erector  centre  is  too  well  known  to 
require  comment.  After  fracture  of  the  lower  dorsal  spines  priapism 
may  last  for  weeks. 

Before  considering  the  question  of  impotence  it  is  well  to  know 
what  constitutes  an  average  amount  of  sexual  strength.  A  man  be- 
tween his  twentieth  and  fiftieth  year,  who  has  no  drain  upon  his 
system,  such  as  is  required  by  unusual  business  anxieties,  or  such 
as  results  from  grief,  disappointment,  etc.,  should  be  able  to  have  in- 
tercourse about  twice  a  week  without  experiencing  any  sense  of 
fatigue  or  exhaustion.  Idiosyncrasy,  surroundings,  or  habits  of  hfe 
may  so  affect  the  individual  that  a  much  more  moderate  indulgence 
would  be  hurtful.  Thus  those  of  lowered  vitality  from  excessive 
work,  deficient  food,  or  organic  or  functional  diseases  may  find  indul- 
gence to  the  extent  above  given  highly  injurious  or  even  impossible, 
while  the  vigorous,  full-blooded  man,  whose  life  is  spent  mainly  in 
the  open  air,  may  far  exceed  this  limit.  The  gauge  as  to  the  healthful 
limit  of  intercourse  should  be  the  sensations  experienced  afterwards. 
These  should  be  rather  of  increased  power,  both  physical  and  mental, 
than  of  exhaustion. 

Erections  may  take  place  shortly  after  birth.  The  power  usually 
departs  about  the  sixty-fifth  year,  though  it  is  often  retained  ten  or 
fifteen  years  longer ;  it  may  be  lost  as  early  as  the  fiftieth  year. 

From  a  chnical  stand-point  impotence  may  be  classified  as  fol- 
lows :  (1)  organic  impotence ;  (2)  psychical  impotence ;  (3)  atonic 
impotence. 

Organic  impotence  implies  the  existence  of  appreciable  lesions 
which  interfere  with  function.  These  may  involve  the  spinal  cord, 
producing  sclerotic  changes  either  in  the  lumbar  centres  or  in  their 
afferent  or  efferent  nerve-fibres.  Thus,  in  lumbar  ataxia,  in  syphilis 
of  the  cord,  and  in  some  cases  of  myelitis,  impotence  is  sometimes 
an  early  symptom  of  the  nerve-affection.     This  is  comparatively  rare. 

The  majority  of  cases  of  organic  impotence  depend  upon  malfor- 
mation of  the  external  genitals.  This  malformation  may  affect  the 
penis,  the  testicles,  both  these  organs,  or  the  surrounding  parts.  The 
penis  may  be  absent,  may  be  rudimental,  may  be  deformed,  may  be 


780  gejStito-urifary  diseases  and  syphilis. 

hypertrophied,  may  be  multiple.  If  the  organ  Is  absent  or  exists 
simply  as  a  rudiment,  cure  is  hopeless.  If  the  mechanical  impedi- 
ment to  coitus  is  dependent  upon  the  small  size  of  a  penis  which  is 
normal  in  other  respects,  the  case  is  not  beyond  help,  since  it  has 
been  shown  in  several  instances  that  use  has  been  quickly  followed 
by  an  increase  in  growth.  Thus,  Wilson  observed  a  man  of  twenty- 
six  years  whose  penis  before  marriage  was  not  larger  than  that  of  an 
eight-year-old  child.  Two  years  after  marriage  this  organ  had  reached 
its  normal  size.  In  the  treatment  of  impotence  in  patients  with  organs 
perfectly  formed  but  markedly  undersized,  the  appHcation  of  a  suction 
apparatus  may  be  beneficial.  This  consists  of  a  cylinder  which  is 
fitted  over  the  penis  and  from  which  the  air  can  be  exhausted ;  as  a 
result  there  is  venous  congestion,  with  temporary  increase  in  the  size 
of  the  organ.  It  is  stated  that  this  increase  will  become  permanent 
if  the  treatment  is  continued  a  sufficient  length  of  time. 

The  abnormal  size  of  the  organ  may  be  an  impediment  to  coitus, 
but  only  relatively  so.  Sometimes  the  penis  is  congenitally  adherent 
to  the  scrotum,  or  is  fixed  to  the  groin  or  the  belly  as  the  result 
of  cicatricial  contraction.  Here  plastic  operations  will  be  necessary, 
according  to  the  special  indications  of  the  case. 

Hypospadia  is  a  frequent  cause  of  impotence,  since  the  downward 
curve  of  the  organ  is  so  greatly  exaggerated  during  erection  that  intro- 
mission is  impossible.  Wounds  and  lacerations  of  the  floor  of  the 
urethra,  sometimes  internal  urethrotomy,  will  produce  the  same  incur- 
vation. 

Fibrous  or  cartilaginous  indurations  of  either  the  sheath  of  the 
penis  or  the  erectile  tissue  materially  interfere  with  coitus,  not 
only  because  of  the  distortion  which  always  becomes  manifest  on 
erection,  but  because  the  erectile  tissue  anterior  to  this  point  of 
induration  remains  entirely  flaccid.  These  indurations  are  irreg- 
ular in  their  distribution,  and  are  common  in  the  rheumatic  and  the 
gouty. 

Deeper  fibrous  indurations,  also  interfering  with  function,  not  un- 
frequently  develop  after  gonorrhoea,  and  in  some  cases  syphilis  seems 
to  be  a  factor  in  the  growth  of  these  lesions.  When  they  appear  in 
the  form  of  gummata  their  specific  origin  is  sufficiently  obvious. 
Calcification  sometimes  takes  place. 

"The  treatment  of  this  condition  is  unsatisfactory.  Gummata  can 
be  made  to  resolve  under  specific  treatment.  7he  hard  nodulations 
and  indurated  plaques  which  are  observed  in  gonorrhoea  or  in  gout, 
or  which  come  without  obvious  cause,  are  extremely  obstinate.  Mas- 
sage and  inunctions  of  mercury  should  be  employed,  together  with 


SEXUAL   WEAKNESS   AND   STEKILITY.  781 

pressure,  which  is  best  applied  by  means  of  a  thin  rubber  bandage. 
The  prognosis  as  to  cure  must  always  be  extremely  guarded. 

Aneurismal  dilatations  of  the  corpora  cavernosa,  whether  con- 
genital or  traumatic,  may  mechanically  prevent  coitus.  Relief  is  here 
obtained  by  the  application  of  firm  rubber  bandages  or  supports. 

Varix  of  the  dorsal  vein  of  the  penis,  though  it  may  attain  large 
dimensions,  rarely  produces  functional  disturbance.  If  it  does,  ex- 
cision is  the  proper  remedy,  A  similar  condition  of  the  lymph-vessels 
may  be  cured  by  excision,  or  by  the  less  radical  means  of  passing 
a  seton  through  the  vessel.  A  tight  frsenum  should  be  remedied  by 
incision. 

Tumors  or  swellings  about  the  genitalia  may  mechanically  inter- 
fere with  function.  Thus,  elephantiasis  of  the  scrotum,  enormous 
oedema  of  the  prepuce,  huge  scrotal  hernias  and  immensely  pro- 
tuberant bellies,  large  scrotal  tumors,  muscular  contractures,  hydro- 
celes, all  may  render  coitus  well-nigh  impossible. 

Malformations  and  diseases  of  the  testicles  may  also  produce  im- 
potence. Such  deformity  is  not  necessarily  attended  with  any  mal- 
formation of  the  penis,  though  this  is  the  rule. 

In  anorchidism — that  is,  congenital  absence  of  the  testicles — 
impotence  is  complete.  Cryptorchids  (those  whose  testicles  have  not 
descended)  are  usually  sterile,  but  not  impotent.  Removal  of  both 
testicles  is  ultimately  followed  by  impotence,  but  this  may  not  come 
on  for  some  years. 

Disorganization  of  the  testicular  structure  either  from  inflamma- 
tion or  from  tumor-growths  is  also  followed  by  the  loss  of  sexual 
power.  If  the  inflammation  is  confined  to  the  epididymis,  however, 
as  in  the  case  of  epididymitis,  the  glandular  structure  of  the  testes 
remaining  intact,  sterility  follows,  but  there  is  no  loss  of  sexual 
strength.  Syphilis,  tubercle,  sarcoma,  carcinoma,  even  though  they 
involve  but  one  testicle,  are  sometimes  associated  with  impotence. 
The  chronic  congestion  and  slow  atrophy  incident  to  pronounced 
varicocele  are  not  infrequently  followed  by  impotence  long  before 
gross  changes  in  the  testicle  have  been  noted. 

Psychical  Impotence. — In  this  form  of  weakness  the  sexual 
organs  are  normally  formed,  and  erection  is  possible,  but  is  not 
properly  under  the  control  of  the  will.  At  times  such  patients  have 
vigorous  erections.  These  occur  in  the  morning  and  on  compara- 
tively slight  provocation.  Under  certain  circumstances,  and  usually 
at  times  when  this  failure  is  most  mortifying,  erections  fail  utterly, 
or,  at  most,  are  so  feeble  as  to  be  of  no  service.  This  form  of  impo- 
tence not  infrequently  attacks  the  newly  married,  who  fancy  that  they 


782  GENITO-TJKINAEY   DISEASES   AND   SYPHILIS. 

suffer  from  some  form  of  sexual  weakness  incident  to  early  self-abuse. 
It  is  sometimes  due  to  a  mental  impression  produced  by  failure  inci- 
dent to  fright,  disgust,  or  other  emotions  at  the  first  attempt. 

Treatment: — The  treatment  of  these  cases  of  psychical  impotence 
should  be  one  calculated  to  make  a  strong  impression  upon  the 
patient's  mind.  He  must  be  examined  with  the  utmost  thoroughness 
both  locally  and  generally.  All  causes  of  local  irritation  must  be  re- 
moved and  every  effort  made  to  improve  his  general  health;  he 
should  be  assured  that  his  weaknesses  merely  temporary  and  that  cure 
will  certainly  result.  Such  patients  have  generally  read  pernicious 
literature,  and  have  usually  consulted  charlatans :  hence  they  need  to 
be  disabused  of  the  teaching  that  masturbation  indulged  in  moderately 
and  for  a  short  time  invariably  produces  disastrous  results. 

In  addition  to  the  general  hygienic  directions,  including  regulation 
of  the  diet,  attention  to  the  bowels,  and  exercise,  some  medicine 
should  be  given  to  these  patients,  and  this  should  be  one  appropriate 
to  their  general  condition,  or,  if  the  health  is  perfect,  one  which  has  a 
tendency  to  act  as  an  excitant  on  the  spinal  centres.  Perhaps  the 
best  prescription  is  the  following : 

R   Strychninse  sulph.,  gr.  ^  ; 

Phosphori,  gr.  j-Jq  ; 

Damianae  ext.,  gr.  iii ; 
M.  et  ft.  pil.  no.  i. 
S. — One  pill  three  times  a  day. 

Under  some  circumstances  moderate  stimulation  by  means  of 
Burgundy  or  champagne  may  be  beneficial,  since  the  patient  is  often 
entirely  cured  after  one  successful  effort.  Absolutely  forbidding  in- 
tercourse acts  at  times  as  an  excellent  stimulus.  Patients  suffering, 
from  this  form  of  impotence  should  be  especially  cautioned  against 
trials  of  their  powers  with  prostitutes,  since  the  circumstances  of  these 
trials  are  little  conducive  to  a  normal  degree  of  sexual  excitement. 

The  term  relative  impotence  implies  lack  of  ability  to  perform  the 
sexual  act  with  certain  partners,  while  with  others  full  strength  may 
be  preserved.  No  rule  can  be  laid  down  for  the  management  of 
such  cases.  Each  must  be  conducted  in  accordance  with  its  merits, 
the  physician  always  throwing  his  influence  on  the  side  of  morality. 
Much  can  sometimes  be  done  by  strong  mental  impression,  usually 
accentuated  by  the  administration  of  drugs.  In  many  cases  impotence 
upon  the  part  of  the  man  is  due  to  the  frigidity  of  the  woman,  who 
does  not  realize  the  profound  effect  of  her  attitude.  Perhaps  the  best 
plan  in  these  cases  is  to  advise  the  man  to  shun  the  society  of  other 
women,  to  live  well,  work  little,  exercise  much. 


SEXUAL    WEAKNESS   AND   STERILITY.  783 

Atonic  Impotence. — Under  this  heading  are  included  those  cases 
of  partial  or  complete  impotence  which  are  due  to  a  weakened  condi- 
tion of  the  lumbar  centres.  When  these  centres  are  in  their  normal 
condition,  erection  should  be  vigorous,  and  coitus  should  be  continued 
for  from  three  to  five  minutes  before  ejaculation,  and  after  ejaculation 
there  should  not  be  immediate  subsidence  of  erection.  In  many 
healthy  young  men  the  erection  can  be  maintained  until  two  emissions 
have  taken  place. 

In  atonic  impotence  (1)  erections  may  be  vigorous,  but  ejacula- 
tions may  be  premature,  occurring  on  contact  or  even  before,  followed 
by  immediate  subsidence  of  erection ;  (2)  erections  may  be  weak  or 
may  be  entirely  wanting. 

The  atonic  condition  of  the  lumbar  centres  may  be  dependent  on 
certain  general  conditions,  such  as  anaemia,  diabetes,  uraemia,  cholse- 
mia,  and  rheumatism.  Sometimes  temporary  impotence  is  one  of 
the  first  signs  of  post-diphtheritic  paralysis.  Wasting  diseases,  such 
as  consumption,  are  usually  accompanied  by  this  form  of  atonic  im- 
potence. Many  drugs  if  taken  until  their  toxic  effects  are  produced 
occasion  failure  of  sexual  power.  Thus,  organic  lead-poisoning,  car- 
bonic acid  gas,  carbon  bisulphide,  antimony,  and  particularly  alcohol, 
tobacco,  and  opium,  may  cause  complete  loss  of  both  power  and 
desire.  Impotence  resulting  from  the  excessive  use  of  tobacco  and 
alcohol  often  long  outlasts  the  other  bad  effects  after  the  habit  has 
been  stopped.  Certain  persons  exhibit  an  idiosyncrasy  towards 
tobacco,  which,  when  taken  in  such  moderation  as  to  produce  no 
constitutional  effect,  may  destroy  both  sexual  desire  and  power. 
It  is  alleged  that  the  cigarette  is  particularly  potent  in  producing  this 
result. 

According  to  Trousseau,  coffee  has  marked  anaphrodisiac  effects, 
and  may  produce  complete  impotence.  This  observation  is  certainly 
not  in  accord  with  the  experience  of  the  majority  of  surgeons,  at 
least  so  far  as  the  moderate  use  of  the  drug  is  concerned.  If  taken 
in  enormous  quantities  it  may  of  course  produce  this  result,  but  rather 
because  of  the  general  nervous  break-down  than  because  of  any 
special  action  on  the  sexual  centres.  Certain  drugs  given  in  phys- 
iological doses  will  produce  a  marked  lessening  of  sexual  power. 
The  bromides  are  particularly  depressing ;  cocaine  is  also  alleged  to 
have  this  effect,  and  morphine  in  certain  individuals  is  markedly 
sedative  to  the  sexual  centres. 

In  accordance  with  the  degree  of  impotence  the  condition  is  said 
to  be  either  irritative  or  paralytic. 

In  the  irritative  form  the  erections  are  either  perfect  or  imperfect. 


784  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

The  emissions  are  always  premature,  quickly  followed  by  subsidence 
of  erection.     The  sexual  desire  is  strong. 

In  the  paralytic  form  erections  are  absent  or  feeble,  desire  is 
wanting ;  during  orgasm  the  semen  drops  from  the  flaccid  penis,  with 
little  or  no  pleasurable  sensation. 

Of  these  two  forms  the  irritative  is  the  more  common.  The  cause 
is  in  the  great  majority  of  cases  a  diseased  condition  of  the  prostatic 
urethra,  the  mucous  membrane  being  exceedingly  hypersemic,  or 
chronically  inflamed,  keeping  the  centres  for  erection  and  ejaculation 
in  a  constant  state  of  reflex  excitability.  This  condition  of  the  pros- 
tatic urethra  may  depend  upon — (1)  gonorrhcEal  inflammation  and  its 
sequel,  stricture ;  (2)  excessive  venery ;  (3)  prolonged  ungratified 
sexual  excitement ;  (4)  strongly  acid  or  irritating  conditions  of  the 
urine.  Of  all  these  causes,  gonorrhoeal  inflammation  and  its  sequel 
stricture  are  the  most  frequent.  In  most  cases  of  acute  gonorrhoea 
the  prostatic  urethra  is  involved  to  a  very  slight  degree,  and  the  dis- 
ease, at  least  in  this  part  of  the  tube,  undergoes  complete  resolution. 
In  a  certain  percentage  of  cases,  however,  the  disease  becomes  firmly 
lodged  in  the  prostatic  follicles,  utricle,  ejaculatory  ducts,  seminal 
vesicles,  or  ampullae  of  the  vasa,  manifesting  itself  only  by  an  occa- 
sional apparently  causeless  outbreak  in  the  form  of  an  acute  attack. 
As  a  consequence  of  the  continued  irritation,  the  mucous  membrane 
of  the  prostatic  urethra  undergoes  catarrhal  alterations,  and  the  sen- 
sory nerve  filaments  so  rich  in  this  part  of  the  tube  are  involved  and 
reflexly  excite  the  centres  for  erection  and  ejaculation.  This  inflam- 
matory and  hyperaesthetic  condition  of  the  posterior  urethra  is  stifl 
further  aggravated  by  the  formation  of  a  stricture. 

Atonic  impotence  from  sexual  excess  is  most  frequently  observed 
among  masturbators,  if  this  habit  can  properly  be  classed  as  "  sexual." 
In  the  recently  married  sexual  excess  is  by  no  means  uncommon, 
but  shortly  regulates  itself.  Occasionally  it  is  continued  for  a  long 
time,  and  then  doubtless  works  permanent  harm :  first,  by  producing 
a  hyperaesthetic  condition  of  the  posterior  urethra,  and  consequently 
one  of  the  forms  of  impotence  ;  next,  by  ultimately  producing  certain 
fibroid  changes  in  the  cord. 

Masturbation  as  a  cause  of  impotence  is  generally  given  prom- 
inence which  is  not  deserved.  This  is  a  habit  which  practically  all 
boys  have  had  at  one  time.  The  popular  belief  as  to  the  injury  which 
even  a  slight  indulgence  in  it  may  cause  leads  those  who  subsequently 
have  sexual  trouble  to  refer  this  back  to  self-abuse.  Even  when  the 
habit  is  continued  for  years  during  the  period  of  youth  and  early 
manhood  it  is  often  followed  by  no  appreciable  ih  effects:  at  least 


SEXUAL   WEAKNESS   AND   STEEILITT.  735 

such  is  the  testimony  of  large  numbers  of  medical  students.  It  is 
however,  undoubtedly  true  that  in  certain  instances,  aside  from  the 
rooted  conviction  of  the  patient,  irritative  and  paralytic  forms  of 
impotence  can  be  referred  directly  to  excessive  masturbation.  The 
physique  and  morale  of  a  masturbator  are  popularly  considered  as 
almost  pathognomonic.  Thus,  such  patients  are  supposed  to  have 
muddy,  pimpled  complexions  ;  a  cold,  moist  surface  ;  hollow,  sunken, 
blinking,  shifting,  watery  eyes ;  lustreless  hair ;  a  timid,  constrained 
manner ;  stooping  shoulders ;  a  tendency  to  swahow  frequently,  par- 
ticularly on  being  embarrassed ;  weak  knees  ;  a  shambling  gait ; 
shrunken  sexual  organs,  and  a  solitary  disposition,  with  incapacity  for 
any  intellectual  effort. 

This  description  no  doubt  applies  to  certain  aggravated  cases.  It 
may,  however,  be  observed  in  neurotics  who  are  not  addicted  to  the 
habit,  and  an  extreme  degree  of  masturbation  may  coexist  with  the 
appearance  and  manners  of  perfect  health. 

Atonic  impotence  from  prolonged  and  ungratified  sexual  desire  is 
usually  observed  in  men  of  neurotic  temperament,  particularly  those 
coming  from  the  rural  districts,  who,  from  the  circumstances  of  their 
life,  are  exposed  to  sexual  excitement,  and  who,  either  from  moral 
reasons  or  for  lack  of  opportunity,  do  not  indulge  in  sexual  inter- 
course. Many  of  these  cases  can  properly  be  classed  as  mastur- 
bators,  since  the  sexual  centres  finally  become  so  irritable  that  orgasm 
occurs  on  the  slightest  provocation,  and  an  opportunity  for  such  pro- 
vocation is  so  constantly  afforded  that  exhaustion  follows. 

The  irritability  often  becomes  so  marked  that  the  slightest  mechan- 
ical frictions  or  jarrings,  such  as  come  from  riding  on  horseback  or  in 
a  jolting  wagon,  occasion  emissions. 

In  these  cases  the  condition  of  sexual  neurasthenia  is  unusually 
well  marked. 

Since  the  ordinary  lesion  of  atonic  impotence,  whatever  its  remote 
cause  may  be,  is  a  hyperaesthetic  condition  of  the  prostatic  urethra,  it 
is  not  unreasonable  to  suppose  that  the  irritation  incident  to  abnormal 
conditions  of  the  urine  may  excite  a  prostatic  hyperaemia,  resulting 
in  the  derangement  of  the  sexual  centres.  That  this  is  the  cause  of 
impotence  associated  with  certain  abnormal  conditions  of  the  urine 
cannot  be  positively  asserted,  since  it  is  possible  that  the  general  con- 
dition which  occasions  the  abnormal  urine  may  also  operate  on  the 
centre  presiding  over  erection.  Thus,  in  complete  impotence  a  careful 
examination  of  the  prostatic  urethra  may  fail  to  show  the  slightest  sign 
of  abnormal  prostatic  condition.  In  cases  of  oxaluria,  however,  the 
return  of  sexual  strength  is  often  coincident  with  the  disappearance 

50 


786  GENITO-URINAKY   DISEASES  AND   SYPHILIS. 

of  calcium  oxalate  in  the  urine.  The  irritating  effect  of  acid  urine  on 
the  prostatic  urethra  is  shown  by  the  persistent  priapism  which  some- 
times accompanies  acute  attacks  of  gout,  in  which  there  is  foQnd  a 
heavy  deposit  of  uric  acid. 

Genito-Urinary  Neuroses. — Atonic  impotence  is  characterized  by 
certain  local  and  general  symptoms,  which  Ultzmann  has  admirably 
described  under  the  general  heading  of  genito-urinary  neuroses.  He 
states  that  the  symptoms  incident  to  a  hyperaemic  or  chronically  in- 
flamed condition  of  the  prostatic  urethra  are  almost  identical  with 
those  observed  in  the  female  as  the  result  of  endometritis.  Both  the 
uterus  and  the  prostate  are  richly  supplied  with  nerves.  In  men  the 
bladder  and  seminal  vesicles  and  prostate  receive  filaments  from  the 
vesical  plexus,  which,  in  turn,  is  made  up  of  anastomosing  branches 
from  the  hypogastric  branch  of  the  sympathetic,  together  with  branches 
from  the  sacral  ganglia  and  from  the  pudendal  plexus  of  the  sacral 
nerves.  This  nerve-supply  sufficiently  explains  why  irritation  of  the 
prostatic  urethra  should  excite  such  reflexes  as  pain  passing  down  the 
inner  surface  of  the  thighs  or  referred  to  the  hip,  the  anus,  the  hypo- 
gastric region,  or  the  small  of  the  back. 

The  general  symptoms  are  those  of  neurasthenia.  Loss  of  mental 
power,  vertigo,  headaches,  shortness  of  breath,  indigestion,  palpita- 
tion, colic,  cough,  emaciation,  wandering  neuralgic  pains,  nervousness, 
and  excitability, — these  and  many  other  symptoms  of  which  neuras- 
thenic females  complain  are  duplicated  in  the  male  suffering  from 
atonic  impotence. 

The  urine  in  these  cases  is  often  abundg^nt  and  of  low  specific 
gravity.  Sometimes  there  is  a  transient  glycosuria.  In  some  cases 
the  urine  is  alkaline  when  it  is  passed,  owing  to  the  presence  of  car- 
bonates. On  heating,  the  earthy  phosphates  are  precipitated.  Indi- 
can  is  observed  particularly  in  those  given  to  sexual  excess.  Tran- 
sient albuminuria  is  sometimes  noted.  Calcium  oxalate  frequently 
appears  in  great  excess.  The  amorphous  crystalhne  salts  of  lime  and 
magnesia  are  also  to  be  found,  together  with  a  few  spermatozoa. 

The  neuroses  of  the  sexual  centre  may  be  either  sensory  or 
motor. 

The  sensory  neuroses  present  an  almost  infinite  variety.  The 
usual  symptoms  complained  of  are  a  sensation  as  though  fluid  was 
trickling  through  the  urethra ;  a  tickling  and  burning  feeling  at  the 
meatus ;  neuralgic,  aching,  or  burning  pains  referred  to  the  testicles, 
anus,  inner  surface  of  the  thighs,  hypogastric  region,  small  of  the 
back,  or  any  of  the  regions  innervated  by  branches  communicating 
with  the  hypogastric  and  sacral  plexuses ;  pain  in  the  testicles  and 


SEXUAL    WEAKNESS   AND   STERILITY.  787 

burning  in  the  meatus  after  ejaculation  ;  and  extreme  sensitiveness  to 
the  passage  of  instruments.  In  aggravated  cases  the  urethra  becomes 
anaesthetic,  and  the  penis  feels  cold,  is  shrivelled,  and  is  sometimes  so 
non-sensitive  that  even  applications  of  an  electric  brush  occasion  no  pain. 

The  motor  neuroses  of  the  urinary  and  genital  systems  may  take 
the  form  of  over-action  or  of  paralysis.  Vesical  irritabihty  is  some- 
times manifested  by  paroxysmal  dribbling  or  even  complete  stoppage 
of  the  urine,  occasioned  either  by  a  lack  of  contraction  of  the  smooth 
muscular  fibres  or  by  spasm  of  the  compressor  urethras.  So-called 
stuttering  urine  may  be  due  to  the  same  cause.  When  the  detrusors 
of  the  bladder  are  involved  in  over-action  there  is  difficulty  in  retain- 
ing water.  Urination  is  frequent  and  urgent,  and  is  usually  not  asso- 
ciated with  pain,  but  sometimes  there  is  marked  tenesmus.  Paralysis 
of  the  sphincters  or  detrusors  is  extremely  rare  ;  in  the  one  case  it 
would  occasion  dribbling  of  the  urine  and  in  the  other  retention. 
The  motor  neuroses  of  the  sexual  system  may  be  manifest  in  the 
form  of  priapism,  or  of  partial  or  complete  impotence,  often  associated 
with  involuntary  seminal  emissions  and  spermatorrhoea.  Priapism  is 
observed  only  in  the  early  stages  of  acute  involvement  of  the  prostatic 
urethra ;  impotence  is  common  in  chronically  inflamed  conditions. 
The  frequent  pollutions  complicating  it  are  due  to  spasm  of  the  de- 
trusors of  the  seminal  vesicles  and  the  vasa  deferentia.  Spermator- 
rhoea or  dribbling  of  the  semen  without  the  sensation  of  an  orgasm  is 
due  to  paresis  of  the  muscular  fibres  of  the  ejacalatory  ducts. 

The  secretory  neuroses  of  the  genital  system  are  manifested  in  the 

form  of  polyspermia,  or  ejaculation  of  abnormal  quantity  of  semen ; 

aspermia,  or  absence  of  semen ;  or  prostatorrhoea,  a  discharge  made 

'  up  of  the  secretions  of  the  prostatic  glands,  the  glands  of  Cowper,  and 

the  urethral  crypts  and  follicles. 

The  Diagnosis  of  Atonic  Impotence. — A  careful  history  will  often 
indicate  whether  impotence  is  due  to  psychological  influence,  to  or- 
ganic changes,  or  to  exhaustion  of  the  lumbar  centres.  Examination 
should  be  made  not  only  of  the  sexual  organs  but  also  of  the  heart, 
of  the  lungs,  and  of  the  system  at  large.  Examination  of  the  urine 
should  never  be  omitted  ;  the  total  quantity  in  the  twenty-four  hours, 
the  specific  gravity,  the  reaction,  the  deposit,  the  presence  or  absence 
of  abnormal  constituents,  must  all  be  carefully  noted.  Microscopic 
search  will  determine  whether  or  not  pus  is  to  be  found.  The  source 
of  this  pus  must  be  discovered  in  the  method  described  when  con- 
sidering the  treatment  of  posterior  urethritis.  The  anus  should  be 
explored  carefully,  since  lesions  in  this  region  may  excite  reflexes 
which  are  referred  to  the  ffenital  tract. 


788  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

Finally,  the  sexual  organs  must  be  carefully  examined;  the  testi- 
cles are  palpated,  and  their  size,  position,  consistence,  sensitiveness, 
and  the  presence  or  absence  of  swellings  and  new  growths  are  noted. 
The  penis  is  similarly  examined,  its  circumference  behind  the  glans 
recorded,  and  the  urethra  carefully  palpated  for  indurations  along  its 
track.  The  prepuce  is  subjected  to  careful  scrutiny,  the  meatus  is  in- 
spected, and  finally  the  urethra  is  explored  exactly  as  in  searching  for 
strictures.  In  many  of  these  cases  spasmodic  contraction  of  the  com- 
pressor urethrae  muscle  is  particularly  marked.  A  full-sized  sound 
passed  to  the  membranous  urethra  and  kept  gently  pressed  against  its 
anterior  opening  will  finally  slip  through,  not  with  a  jump,  but  rather 
as  though  an  attempt  were  being  made  to  pass  it  through  a  tight,  flex- 
ible tube  without  previously  lubricating  it.  Sometimes  it  seems  to  be 
drawn  in  with  a  swallowing  motion.  During  the  introduction  of  the 
instrument  not  only  should  the  points  of  resistance  to  its  entrance  be 
noted,  but  also  areas  of  unusual  tenderness.  The  posterior  urethra 
is  extremely  sensitive ;  in  cases  of  the  paralytic  type,  however,  the 
passage  of  a  sound  is  absolutely  painless. 

If  the  meatus  is  so  narrowed  that  it  will  not  admit  a  full-sized 
sound  it  should  be  cut.  Urethroscopic  examination  is  rarely  neces- 
sary in  these  cases,  at  least  until  the  failure  of  ordinary  treatment 
suggests  the  possibility  of  some  unusual  pathological  condition,  such 
as  polypoid  growth. 

An  examination  thus  conducted  will  show  a  hyperaemic  or  in- 
flammatory condition  of  the  posterior  urethra,  either  associated  with 
stricture  or  other  obstructive  lesion,  or  simply  remaining  as  the  result 
of  repeated  prolonged  congestion  or  previous  acute  inflammation. 

The  prognosis  of  atonic  impotence  is  good,  except  in  the  most 
advanced  cases.  When  strictures  or  granular  patches  in  the  anterior 
urethra  are  the  exciting  causes,  the  cure  of  these  is  followed  by  the 
disappearance  of  the  symptoms  of  impotence. 

When  the  symptoms  are  due  to  the  persistence  of  a  posterior 
urethritis,  local  applications  are  curative.  When  impotence  is  caused 
by  impaired  health,  the  outlook  is  favorable,  provided  the  general 
condition  can  be  improved.  Even  though  erections  are  entirely 
absent  at  times  when  they  are  most  desired,  or  are  of  such  short 
duration  as  to  be  of  no  practical  service,  if  the  patient  has  volup- 
tuous dreams  with  erection,  and  particularly  if  he  has  an  occasional 
morning  erection,  the  chances  of  ultimate  cure  are  good.  The  prog- 
nosis is  bad  only  in  such  cases  as  have  no  erection  at  any  time,  the 
semen  dribbhng  without  pleasurable  sensations,  and  the  penis  being 
cold,  shrivelled,  and  non-sensitive. 


SEXUAL   WEAKNESS   AND   STERILITY.  789 

Treatment — The  treatment  of  atonic  impotence  must  be  both  gen- 
eral and  local.  The  daily  life  of  the  patient  should  be  carefully  regu- 
lated. The  hours  of  sleep,  the  diet,  the  amount  and  kind  of  exercise, 
should  all  be  prescribed.  The  bowels  should  be  kept  regular,  and 
general  treatment  should  be  instituted  when  this  is  required  to 
combat  the  pathological  conditions  of  the  urine.  During  treatment 
the  patient  must  be  particularly  cautioned  against  venereal  excite- 
ment of  any  kind,  whether  from  reading,  conversation,  or  associa- 
tions, and  against  testing  the  efficacy  of  his  treatment  by  an  occasional 
trial  of  strength. 

All  sources  of  reflex  irritation  must  be  removed.  Fissures  or 
hemorrhoids  in  the  rectum,  phimosis,  or  narrow  meatus  should  re- 
ceive prompt  surgical  treatment.  Some  cases  of  impotence  have 
been  cured  by  the  removal  of  a  hemorrhoidal  mass,  by  the  slitting 
of  the  meatus,  or  by  treatment  directed  to  the  destruction  of  lumbri- 
coids  or  ascarides.  Even  a  moderate  degree  of  varicocele  should  be 
remedied  either  by  a  suspensory  bandage  or  by  operation. 

If  in  the  course  of  treatment  the  thoughts  are  in  spite  of  every 
effort  turned  to  sexual  topics,  the  patient  should  be  instructed  to 
counteract  this  tendency  in  its  very  beginning  by  vigorous  and  pro- 
longed exercise  and  cold  baths. 

The  local  treatment  has  for  its  end  the  restoration  of  the  entire 
urethra  to  a  normal  condition.  Strictures  must  be  cured  by  section 
or  dilatation,  granular  patches  healed  by  applications  through  the  en- 
doscope, and  hyperaesthetic  and  inflammatory  conditions  of  the  pos- 
terior urethra  treated  by  irrigation,  instillations,  and  the  passage  of 
full-sized  cold  steel  sounds,  or  by  the  use  of  the  psychrophore. 

The  sound  should  be  introduced  every  third  or  fourth  day  and 
should  be  of  full  normal  calibre.  When  the  urethra  is  extremely 
hyperaesthetic,  injections  of  cocaine,  first  into  the  anterior  urethra, 
then  into  the  posterior  part  of  the  canal  by  means  of  an  instillator, 
will  render  instrumentation  comparatively  painless. 

When  there  are  distinct  evidences  of  congestion  or  inflammation 
in  the  posterior  urethra,  in  addition  to  the  sound,  irrigation  and  instil- 
lation will  usually  be  necessary  before  cure  can  be  accomplished. 
(See  Treatment  of  Chronic  Posterior  Urethritis.) 

When  inflammation  is  absent,  or  after  it  has  been  cured,  if  hyper- 
sesthesia  still  persists,  this  is  best  combated  by  the  prolonged  applica- 
tion of  cold.  The  passage  of  a  cold  sound  accomplishes  this  end  in 
an  imperfect  way,  since  the  metal  is  soon  heated.  The  psychrophore 
(Fig.  253)  will,  however,  permit  of  a  continuous  cold  application  for  as 
long  a  period  as  is  desired.     This  instrument  is  made  in  the  form  of 


790 


GENITO-UKINARY   DISEASES   AND   SYPHILIS. 


a  hollpw  sound,  through  the  curved  extremity  of  which  a  stream  of 
water  of  tlie  desired  temperature  constantly  flows.  It  is  so  devised 
that  the  sheath  of  the  instrument  which  passes  through  the  anterior 
urethra  is  not  kept  cold  by  the  liquid,  which  flows  through  pipes  con- 
tained in  the  sheath,  but  separated  from  its  walls  by  air-spaces.  It 
is  only  in  the  terminal  three  inches  that  the  water  is  allowed  to  come 
immediately  in  contact  with  the  walls  of  the  instrument. 


Fig.  253. 


Psychrophore. 

The  psychrophore  should  be  as  large  as  the  normal  calibre  of  the 
urethra.  It  is  introduced  until  its  curved  portion  occupies  the  mem- 
branous and  prostatic  urethrse  ;  then  a  current  of  water  of  the  desired 
temperature  is  allowed  to  pass  slowly  through  it,  thus  maintaining  the 
chamber  at  its  end  at  about  the  temperature  of  the  water.  In  cases 
of  hypereesthesia  attended  by  the  irritative  form  of  atonic  impotence, 
cold  water  is  most  serviceable.  The  temperature  of  this  should  be 
between  40°  and  50°  F.,  and  the  treatment  should  be  kept  up  for  from 
five  to  ten  minutes  every  second  or  third  day.  In  the  paralytic  form 
of  atonic  impotence  hot  water  from  106°  to  110°  F.  should  be  chosen. 

Heat  or  cold  may  be  applied  through  the  rectum  in  the  form 
of  injections,  or  a  rubber  bag  introduced  within  the  grasp  of  the 
sphincter. 

Rectal  injections  are  so  planned  that  the  solution  of  choice  (sodium 
chloride  solution,  seven-tenths  per  cent.)  is  thrown  upward  in  a  forcible 
stream  against  the  prostate,  and  is  allowed  to  escape  immediately  with- 
out distending  the  bowel.  This  end  is  readily  accompKshed  by  the 
instrument  pictured  in  Fig.  226.  The  selection  of  heat  or  cold  will 
depend  upon  the  type  of  disease  and  the  sensations  of  the  patient. 
At  least  a  quart  of  solution  should  be  used  daily.  Dry  heat  or 
cold  through  the  rectum  is  readily  applied  by  means  of  a  modified 
Barnes's  bag  inserted  into  the  rectum  and  distended  with  either  hot 
or  cold  water.      This   method   of  treatment  is  to  be  commended, 


SEXUAL    WEAKNESS   AND   STEKILITY.  79I 

since  it  adds  to  the  beneficial  effects  of  temperature  those  incident 
to  pressure. 

When  by  the  means  already  described  urethral  hyperaesthesia  has 
been  entirely  subdued  and  yet  impotence  still  persists,  other  methods 
of  treatment  must  be  employed  to  restore  power  to  the  weakened 
centres  and  also  to  the  muscles  concerned  in  erection  and  ejaculation. 
Full  doses  of  strychnine  are  advisable  in  these  cases,  and  particularly 
strychnine  in  combination  with  phosphorus  and  damiana.  Massage 
and  general  electricity  are  useful. 

The  needle  spray  apphed  once  a  day  to  the  external  genitalia  at 
the  time  of  the  morning  bath  is  tonic  and  stimulating.  The  water 
should  be  driven  forcibly  against  the  inner  surfaces  of  the  thighs,  the 
hypogastric  region,  the  buttocks,  and  the  small  of  the  back,  and 
should  be  alternately  as  hot  as  can  be  borne  and  as  cold  as  possible. 
The  applications  should  be  continued  for  from  two  to  five  minutes. 

Electricity  is  one  of  the  most  valuable  means  of  stimulating  the 
sexual  centres.  Both  the  galvanic  and  the  faradic  current  seem  to  be 
of  value.  It  is  employed  not  only  as  a  general  nerve  tonic,  but  also  as 
a  means  of  directly  exercising  the  perineal  muscles  concerned  in  erec- 
tion. The  current  should  be  first  applied  to  the  spine,  and  then  used 
locally.  The  positive  pole  is  placed  over  the  lumbar  region  ;  the  other 
is  carried  to  the  perineum,  the  anus,  the  hypogastric  region,  or  the 
prostatic  urethra,  and  swept  over  the  external  genitaha,  the  buttocks, 
and  the  inner  surface  of  the  thighs. 

The  rectal  electrode  is  serviceable  in  cases  of  imperfect  erection 
and  loss  of  power  of  ejaculation ;  it  is  particularly  valuable  because 
by  means  of  a  slowly  interrupted  current  it  exercises  the  entire 
perineal  group  of  muscles.  The  important  part  these  muscles  play 
in  erection  has  been  shown  already,  and  restoration  of  their  vigor  by 
the  use  of  electricity  is  often  followed  by  complete  recovery  of  sexual 
strength.  The  application  should  last  from  fifteen  to  twenty  minutes 
and  be  repeated  daily  for  several  weeks  or  months. 

The  urethral  electrode  allows  the  current  to  be  applied  directly  to 
the  prostatic  urethra.  Both  galvanic  and  faradic  currents  are  em- 
ployed, the  gauge  as  to  strength  usually  being  the  sensation  of  the 
patient.  An  electrode  properly  placed  and  conveying  a  slowly  in- 
terrupted current  strongly  exercises  the  sphincter  of  the  bladder, 
the  compressor  urethras,  and  the  unstriped  fibres  of  the  prostate, 
probably  including  those  of  the  ejaculatory  ducts  :  hence  in  cases  of 
spermatorrhoea  this  treatment  is  particularly  serviceable.  When  the 
galvanic  current  is  employed  it  should  never  be  of  such  strength  as 
to  occasion  electrolytic  action. 


792  GENITO-IJKIISrAEY  DISEASES   AND   SYPHILIS. 

In  some  cases  which  do  not  yield  to  other  treatment,  a  complete 
course  of  hydrotherapy,  including,  as  it  does,  change  of  air,  sur- 
roundings, and  occupation,  is  sometimes  advisable,  or,  in  place  of  this, 
prolonged  out-door  but  not  solitary  life. 

Two  of  the  symptoms  of  atonic  impotence  are  so  conspicuous  as 
to  deserve  separate  consideration :  these  are  prostatorrhoea, — that  is, 
intermittent  discharge  of  prostatic  fluid  from  the  urethra, — and  sper- 
matorrhoea, or  involuntary  loss  of  semen. 

Prostatorrhoea  is  characterized  by  a  discharge  during  defecation, 
after  urination,  and  at  times  of  sexual  excitement,  of  a  white-of-egg- 
like  substance  from  the  urinary  meatus.  This  same  substance  may 
be  caused  to  flow  from  the  meatus  by  pressure  upon  the  prostate 
through  the  rectum.  Microscopic  examination  of  the  discharge  shows 
that  it  is  made  up  of  leucocytes,  cylindrical  epithelium,  and  concentric 
amyloid  concretions ;  Bottcher's  sperm  crystals  and  casts  of  the  pros- 
tatic ducts,  closely  resembling  renal  casts,  are  also  found.  Blood  is 
rarely  present. 

Prostatorrhoea  is  dependent  on  a  chronic  catarrhal  condition  of 
the  prostatic  urethra,  involving  the  ducts  and  follicles.  Gonorrhoea 
and  prolonged  ungratified  or  unnaturally  gratified  sexual  excitement 
most  often  produce  this  catarrhal  condition.  On  examination  of  the 
prostate  per  rectum  it  will  not  usually  be  found  materially  increased 
in  size,  although  occasionally  the  nodular  outline  indicative  of  follicu- 
lar prostatitis  can  be  felt.  The  most  prominent  symptoms  of  this 
condition  are — (1)  A  marked  condition  of  sexual  neurosis,  perhaps  a 
reflex  from  the  catarrhal  region,  usually  aggravated  because  the 
patient  believes  that  the  discharge  is  semen  and  that  thus  his  strength 
is  draining  from  him.  (2)  A  discharge  at  stool  and  after  urination 
of  viscid  prostatic  mucus.  The  hypersecretion  is  going  on  steadily, 
but,  owing  to  the  tonic  contraction  of  the  compressor  urethrge  muscle, 
cannot  pass  forward  until  the  resistance  of  the  muscle  is  overcome  by 
the  pressure  of  hardened  masses  of  faeces,  or  by  the  reflex  required 
by  the  act  of  micturition.  In  some  aggravated  cases  the  compressor 
urethrse  muscle  becomes  so  weak  that  the  discharge  will  flow  for- 
ward almost  constantly.  If  many  spermatozoa  are  found  in  the  dis- 
charge, the  case  must  be  regarded  as  one  of  spermatorrhoea.  (3)  Fre- 
quency and  some  urgency  in  urination,  tickling  or  aching  sensations 
in  the  prostatic  urethra,  and  reflex  pains  in  the  back,  rectum,  hypo- 
gastrium,  and  down  the  inner  surface  of  the  thighs.  (4)  Partial  or 
complete  impotence.  Exceptionally,  beyond  the  prostatic  discharge, 
there  are  no  symptoms. 

The   prognosis  of  prostatorrhoea   is   usually  good.     Even  when 


SEXUAL   WEAKNESS   AND   STEKILITY.  793 

habitual  masturbation  causes  prostatorrhoea,  the  j)rognosis  is  fairly 
good,  provided  the  paralytic  form  of  impotence  has  not  been  reached 
and  the  patient  has  some  strength  of  will  on  which  to  build, 

Treoiment. — The  treatment  is  especially  that  directed  to  the  cure 
of  congestion  or  inflammations  of  the  posterior  urethra.  When  a  de- 
pressed condition  of  the  system  or  irritating  urine  seems  to  be  the 
cause  of  prostatorrhoea,  corrections  of  these  departures  from  health 
may  be  followed  by  prompt  cure. 

It  is  particularly  important  that  the  bowels  should  be  kept  open. 
Magnesium  sulphate  or  Hunyadi  water  in  the  morning  will  accom- 
plish this ;  fluid  extract  of  cascara,  twenty  drops  three  times  a  day, 
is  useful.  Both  exercise  and  diet  must  be  carefully  regulated. 
Horseback  or  bicycle  riding  should  be  forbidden  in  cases  of  fol- 
licular prostatitis,  or  in  those  whose  symptoms  after  a  trial  are  made 
distinctly  worse.  Often  these  exercises  provide  a  species  of  mas- 
sage for  the  prostate  which  acts  most  beneficially  upon  it.  The 
prostatic  mucous  membrane  seems  to  be  particularly  sensitive  to  the 
effect  of  chilling :  hence  patients  suffering  from  prostatorrhoea  must 
be  carefully  protected  against  wet  feet,  draughts,  and  other  causes  of 
cold. 

When  there  is  pus  in  the  discharge  or  in  the  shreds  found  in  the 
urine,  the  treatment  is  that  appropriate  to  posterior  urethritis. 

The  medical  treatment  is  of  minor  importance,  but  should  none 
the  less  receive  attention.  When  the  inflammation  is  one  of  long 
standing,  stimulants  may  be  required.  Here  oil  of  sandal  wood  in 
ten-minim  doses  three  times  a  day,  taken  one  hour  after  meals,  will 
be  of  great  help.  Cubebs,  copaiba,  turpentine,  and  cantharides,  the 
latter  in  small  doses,  are  all  useful.  When  the  bladder  is  irritable, 
belladonna,  fifteen  drops  of  the  tincture  three  times  a  day,  is  bene- 
ficial. When  the  urethra  is  especially  hypereesthetic,  and  particu- 
larly in  cases  of  marked  sexual  neurasthenia,  potassium  bromide, 
administered  in  twenty-grain  doses  three  times  a  day,  may  quiet  the 
nervous  symptoms.  As  a  rule,  tonics,  compound  syrup  of  hypophos- 
phites  in  teaspoonful  doses,  emulsion  of  cod-liver  oil  with  iodide  of 
iron,  and  iron  and  nux  vomica,  should  be  recommended.  We  have 
found  hyoscine  and  hyoscyamine  sulphate  particularly  efficacious  in 
the  non-inflammatory  forms  of  prostatorrhoea. 

It  is  upon  local  treatment,  however,  that  most  reliance  must  be 
placed.  This  consists  in  the  use  of  steel  sounds,  the  psychrophore, 
the  prostatic  dilator,  the  rectal  bag,  the  rectal  douche,  irrigations,  and 
instillations. 

Instillations  in  these  cases  should  be  more  astringent  than  in  an 


794  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

ordinary  inflammatory  case :  thus,  fluid  extract  of  hydrastis  or  pure 
zinc  sulphate,  twenty  grains  to  the  ounce,  may  be  employed.  Soluble 
prostatic  bougies  are  prescribed  only  when  it  is  impossible  for  the 
patient  to  see  his  physician.  Under  these  circumstances  instruction 
may  be  given  as  to  the  proper  method  of  inserting  these  bougies. 
The  latter  may  be  ordered  in  accordance  with  the  indications,  using 
the  strongest  and  most  astringent  in  the  oldest  cases.  Among  the 
most  useful  bougies  is  one  containing  the  following : 

Zinc  sulphate,  gr.  ii ; 

Carbolic  acid,  Tt\^ii ; 

Fluid  extract  of  hydrastis,  Ti\,xv. 

The  prostatic  dilator  (see  Fig.  63)  is  sometimes  of  service.  It 
probably  accomplishes  its  good  effect  by  mechanically  emptying  the 
inflamed  folKcles  and  thus  allowing  the  instillation,  which  should 
immediately  follow  the  stretching,  to  reach  to  the  deeper  parts  of  the 
diseased  mucous  membrane ;  the  solutions  of  choice  and  the  method 
of  instrumentation  have  been  given.  (See  Chronic  Posterior  Ureth- 
ritis.) Stretching  by  means  of  the  dilator  should  be  carried  as  high 
as  No.  36  of  the  French  scale  and  not  higher  than  No.  44.  Full 
dilatation  of  the  prostatic  urethra  by  means  of  ordinary  sounds  is 
impossible,  since  an  instrument  of  sufficient  size  to  overstretch  the 
membranous  urethra  fits  loosely  in  the  wider  prostatic  portion  of  the 
tube. 

Blisters  applied  to  the  perineum  and  the  hypogastric  region  have 
been  warmly  commended.  If  used,  the  bhstered  area  should  be 
small,  the  application  of  the  vesicant  being  frequently  repeated. 

Electricity  is  sometimes  a  useful  agent  in  prostatorrhoea.  The 
galvanic  current  is  most  popular,  one  pole  being  applied  to  the  lumbar 
region,  the  other  to  the  prostatic  urethra. 

Usually  it  is  best  strictly  to  interdict  intercourse  ;  though  when 
prostatorrhoea  occurs  in  married  men  as  the  result  of  long-continued 
excess  it  is  wise  for  a  time  to  allow  of  moderate  indulgence,  since 
otherwise  the  local  congestion  incident  to  prolonged  excitement 
without  gratification  might  counteract  the  effect  of  treatment.  The 
advisability  of  allowing  moderate  intercourse  must  be  determined 
by  the  immediate  effect ;  thus,  if  the  discharge  is  increased,  and  par- 
ticularly if  the  patient  feels  exhausted  and  suffers  from  lumbar  pains, 
intercourse  must  be  forbidden. 

Under  proper  treatment  recovery  may  result  in  from  one  to  three 
months,  though  in  some  cases  a  much  longer  period  of  time  is  required. 
Certain  cases  are  aggravated  by  local  treatment.    Under  these  circura- 


SEXUAL   WEAKNESS  AND   STEEILITY.  795 

stances  it  is  advisable  to  make  a  complete  change  of  life  and  surround- 
ings. An  active  open-air  life  will  sometimes  be  followed  by  ultimate  cure. 

Involuntary  Seminal  Emissions. — These  may  be  due  to  erotic 
dreams,  or  may  be  occasioned  by  a  local  hyperaesthesia  so  marked 
that  stimuli  too  feeble  to  produce  any  effect  in  health  become  suffi- 
cient to  excite  ejaculation.  The  involuntary  emission  may  occur  at 
night  or  in  the  day,  and  the  semen  may  escape  intermittently  in  the 
form  of  pollutions  or  as  an  almost  constant  flow. 

Nocturnal  Pollutions. — In  continent  men  it  is  entirely  compatible 
with  health  to  have  nocturnal  pollutions  as  frequently  as  once  a  week. 
When  during  the  waking  hours  there  has  been  prolonged  sexual 
excitement,  these  pollutions  may  occur  much  more  frequently,  two  or 
three  times  a  week,  and  yet  indicate  no  abnormal  local  or  general 
condition.  It  is,  however,  by  no  means  rare  to  fmd  continent  men 
in  perfect  health  who  have  no  pollution  for  weeks  or  months  at  a 
time ;  it  is  especially  in  those  who  are  kept  constantly  occupied  both 
in  mind  and  in  body  that  this  is  observed.  After  prolonged  exer- 
tion, either  mental  or  physical,  it  is  not  uncommon  for  two  or  three 
emissions  to  occur  in  a  single  night.  The  pollutions  may  be  unat- 
tended by  voluptuous  dreams,  and  may  occur  with  the  penis  flaccid. 
It  is  possible  for  the  variations  just  named  to  be  found  within  the 
limits  of  perfect  health. 

The  gauge  as  to  whether  the  loss  can  be  considered  indicative  of 
either  local  or  general  weakness  is  the  condition  of  the  patient.  If 
aside  from  imaginary  sulfe rings  these  pollutions  are  followed  by 
weakness,  backache,  and  mental  depression,  if  they  are  habitually 
frequent,  and  particularly  if  they  are  associated  with  sexual  weakness 
or  impotence,  they  must  be  regarded  as  an  index  of  disordered  func- 
tion. At  first  nocturnal  pollutions,  even  though  they  occur  with 
extreme  frequency,  are  usually  associated  with  full  sexual  strength ; 
later,  as  the  excitability  of  the  ejaculatory  centre  becomes  weakened, 
there  is  usually  developed  a  more  or  less  profound  form  of  sexual 
weakness. 

Diurnal  pollutions  indicate  a  degree  of  sexual  weakness  much 
more  marked  than  do  even  excessive  seminal  losses  occurring  during 
sleep.  In  these  cases  the  slightest  psychical  or  physical  stimulus  is 
often  sufficient  to  excite  emission.  The  presence  of  women,  the 
jarring  of  a  wagon,  manipulations  necessary  for  cleaning  the  fore- 
skin, or  even  examination  of  the  skin  surface  around  the  genitalia, 
may  occasion  pollutions.  The  erections  are  usually  imperfect,  the 
voluptuous  sensations  are  blunted,  and  immediately  after  emission 
there  is  subsidence  of  the  erection. 


796  GENITO-UKINAEY  DISEASES   AND   SYPHILIS. 

Spermatorrhcea. — This  condition  is  characterized  by  oozing  out  of 
the  semen  without  erection  or  pleasurable  sensation.  It  is  occasioned 
by  erotic  thoughts,  or  by  light  mechanical  stimuli,  or  may  occur  in- 
dependently of  these  causes,  the  semen  escaping  with  the  urine  or 
during  defecation  as  in  prostatorrhoea. 

Spermatorrhoea  in  the  sense  of  a  constant  flow  of  semen  from  the 
urethra  is  extremely  rare.  It  is  occasionally  observed  in  vigorous 
men  much  given  to  sexual  excess  who  become  suddenly  continent. 
In  these  cases  a  whitish  discharge  is  observed,  which  on  examination 
is  found  to  be  swarming  with  spermatozoa.  In  such  cases  sperma- 
torrhoea is  unassociated  with  impotence,  and  there  is  often  but  a 
moderate  degree  of  sexual  hypochondriasis.  Slight  and  intermittent 
spermatorrhoea  is  comparatively  common  in  chronic  posterior  ureth- 
ritis, even  when  there  is  no  appreciable  functional  weakness. 

A  typical  sufferer  from  spermatorrhoea  represents  the  most  aggra- 
vated form  of  impotence.  Both  desire  and  power  of  erection  are 
usually  lost,  and  voluptuous  sensations  are  excited  only  by  the 
strongest  stimuli. 

The  diagnosis  of  spermatorrhoea  must  be  founded  on  microscopic 
examination.  A  few  spermatozoa  in  a  mucous  discharge  are  probably 
accidental,  and  do  not  necessarily  indicate  any  pathological  condition. 
If  great  numbers  are  constantly  present  in  the  urine  and  in  the  dis- 
charge occurring  after  defecation  or  urination,  it  may  be  assumed  that 
there  is  a  condition  of  true  spermatorrhoea. 

The  differential  diagnosis  from  prostatorrhoea  is  not  particularly 
important  except  from  a  prognostic  stand-point,  since  the  treatment 
of  aggravated  forms  of  the  two  affections  is  very  much  the  same. 

Treatment. — The  treatment  of  involuntary  seminal  emissions  is 
that  appropriate  to  atonic  impotence,  since  both  these  conditions  are 
symptomatic  of  an  irritable  condition  of  the  lumbar  centres. 

The  treatment  of  nocturnal  pollutions  must  be  conducted  upon 
rational  principles.  First,  it  must  be  determined  whether  such  pollu- 
tions indicate  an  abnormality.  Usually  the  patients  applying  for  the 
relief  of  this  condition  have  seminal  losses  not  more  frequently  than 
is  consistent  with  perfect  health.  When  the  loss  is  excessive,  or 
even  when  it  is  strictly  confined  within  normal  limits,  if  the  patient 
is  markedly  hypochondriacal,  a  vigorous  treatment  should  be  insti- 
tuted. General  hygienic  directions  are  given ;  the  patient  is  particu- 
larly cautioned  against  sexual  excitement.  By  means  of  a  saline  or 
other  mild  laxative  the  bowels  are  opened  at  night  before  retiring. 
The  bed  should  be  hard,  the  covering  light ;  sleeping  in  the  dorsal 
decubitus  should  be  avoided  by  tying  a  towel  around  the  waist  with 


SEXUAL   WEAKNESS   AND   STEKILITY.  797 

a  knot  over  the  spine.  An  alarm-clock  is  set  to  ring  about  four 
hours  after  the  time  of  going  to  bed,  the  patient  then  rising  and 
passing  water.  Before  going  to  bed,  light  calisthenics  to  the  point 
of  perspiration,  cool  sponge  bath,  and  brisk  rubbing  down  are 
advisable. 

When  in  spite  of  these  precautions  erections  and  emissions  occur, 
an  anti-pollution  ring  may  be  worn.  This  is  designed  to  fit  comfort- 
ably about  the  penis  when  the  organ  is  in  its  flaccid  condition ;  when 
it  becomes  erect  a  number  of  sharp  teeth  dig  into  the  skin,  and  by  the 
pain  they  excite  wake  the  patient.  All  sources  of  reflex  irritation 
must  be  sought  for  and  removed.  Medication  directed  to  subduing 
the  irritability  of  the  lumbar  centres  is  sometimes  most  serviceable. 
Potassium  bromide,  from  thirty  to  ninety  grains  at  bedtime,  is  tempo- 
rarily useful.  Atropine,  one  three-hundredth  of  a  grain  three  times 
a  day,  or  twice  this  quantity  given  at  bedtime ;  hyoscine,  one  two- 
hundredth  of  a  grain ;  hyoscyamine  sulphate,  one  one-hundred-and- 
fiftieth  of  a  grain ;  lupuline,  one-twentieth  of  a  grain  three  times  a 
day  ;  and  monobromate  of  camphor,  five  grains  three  times  a  day,  are 
all  serviceable  :  hyoscyamine  is  almost  a  specific. 

The  treatment  of  diurnal  pollutions  is  conducted  on  the  same 
general  principles  as  that  of  atonic  impotence,  except  that,  as  this 
symptom  usually  denotes  an  advanced  catarrhal  alteration  of  the 
prostatic  urethra,  strong  applications  to  this  portion  of  the  canal  are 
usually  necessary.  In  addition  to  the  various  instillations  the  solid 
stick  of  silver  nitrate  may  be  used  advantageously.  The  hot  rectal 
douches,  the  needle  spray,  electricity,  and  the  treatment  appropriate 
to  nocturnal  pollutions  are  applicable  in  these  cases. 

In  cases  of  seminal  incontinence  (spermatorrhoea)  the  treatment 
should  be  directed  towards  restoring  tone  to  the  paretic  vessels  and 
revitalizing  the  exhausted  lumbar  centres.  Of  the  drugs  employed, 
strychnine,  one-twentieth  of  a  grain  four  times  a  day ;  damiana,  five 
grains  three  times  a  day  ;  phosphorus,  one-hundredth  of  a  grain  three 
times  a  day ;  fluid  extract  of  ergot,  a  teaspoonful  three  times  a  day ;  and 
arsenous  acid,  one-fortieth  of  a  grain  three  times  a  day,  are  valuable. 
Electricity  is  particularly  serviceable.  The  psychrophore,  hot  rectal 
douches,  strong  posterior  applications,  particularly  the  solid  stick  of 
silver  nitrate,  or  instillations  of  pure  iodine  or  of  iodine  and  carbolic 
acid  mixed,  will  give  the  best  results. 

Many  cases  of  sexual  weakness  are  made  worse  by  treatment.  If 
after  one  thorough  trial  of  methods  which  careful  examination  has 
shown  most  hkely  to  be  successful  there  is  no  improvement,  local 
treatment,  in  the  absence  of  local  lesions,  should  be  abandoned,  the 


798  GENITO-UKINAEY  DISEASES   AND   SYPHILIS. 

physician  devoting  his  whole  attention  to  the  improvement  of  the 
general  health  of  the  patient. 

Priapism. — Persistent  penile  erections  unaccompanied  by  sexual 
desire,  at  times  extremely  painful,  and  interfering  with  the  function 
of  urination  are  usually  expressions  of  spinal  lesion,  particularly  that 
due  to  syphilis,  to  beginning  sclerosis,  or  to  the  infiltration  of  leukaemia. 
Cerebellar  hemorrhage  and  spinal  trauma  sufficiently  severe  to  cause 
paraplegia  also  produce  this  symptom.  Intermittent  priapism,  usually 
annoying  rather  than  painful,  is  a  frequent  accompaniment  or  sequel 
of  prolonged  mental  strain  in  neurasthenic  men. 

The  prognosis  is  grave  from  the  stand-point  of  the  causative  lesion. 

The  treatment  of  the  intermittent  neurasthenic  forms  of  this  affec- 
tion should  aim  at  rest  and  improvement  of  the  general  health.  If 
a  thorough  examination  excludes  cerebral  lesions,  then  patients  can 
be  assured  that  the  symptom  which  to  them  is  often  most  alarming 
has  no  serious  significance,  and  that  local  treatment  is  not  indi- 
cated. Small  doses  of  hyoscyamin  sulphate,  gr.  2-^-0,  twice  daily,  are 
often  serviceable,  but  bromides  or  other  depressants  are,  as  a  rule, 
distinctly  hurtful.  Exceptionally  a  local  lesion  such  as  chronic  pos- 
terior urethritis  may  cause  intermittent  priapism,  and  in  such  case 
direct  treatment  is  indicated.  Exceptionally,  even  in  the  absence  of 
local  lesions,  the  passage  of  a  sound  is  helpful.  The  observance  of 
general  hygienic  regulations  and  treatment  directed  to  the  rehef  of 
gout,  rheumatism,  or  other  systemic  condition  which  may  require 
medication  are  followed  by  cure. 

Priapism  dependent  upon  syphilis  of  the  cord  calls  for  massive 
doses  of  mercury  and  the  iodides.  When,  because  of  leuksemic  infil- 
trate or  pressure  on  the  cord  from  chronic  inflammatory  exudate  or 
tumor,  the  erection  becomes  persistent  and  hurtful,  ice-bags  in  the 
rectum  may  be  helpful.  Section  of  the  pudic  nerves  may  be  needful 
to  give  relief  in  rare  cases. 

Impotence  in  the  Female. — Impotence  in  the  female,  in  the 
sense  of  inability  to  accompMsh  the  sexual  act  under  normal  and 
lawful  conditions,  may  be  classified  under  the  following  headings : 
(1)  intromission  of  the  male  organ  is  impossible  ;  (2)  intromission  is 
possible,  but  either  excites  pain  or  fails  to  cause  orgasm. 

Intromission  of  the  male  organ  may  be  prevented  by  congenital 
or  acquired  obstruction,  or  by  obliteration  of  the  vulva  and  vagina. 
The  congenital  anomalies  may  appear  in  the  form  of  absence  of  the 
vagina,  extreme  narrowing,  division  into  two  parts,  each  too  small 
to  allow  of  intromission,  or  opening  in  abnormal  positions,  as,  for 
instance,  into  the  rectum.     The  vulva  may  be  obstructed  by  adhe- 


SEXUAL   WEAKNESS   AND   STEKILITY.  799 

sions,  by  hypertrophy  of  the  labia  or  clitoris,  or  by  a  rigid  or  imper- 
forate hymen.  Acquired  obstruction  may  depend  upon  cicatricial 
contraction,  inflammatory  swelling,  new  growths,  or  hypertrophy  of 
the  parts. 

The  treatment  of  impotence  dependent  upon  congenital  absence 
of  the  vulva  or  vagina  is  of  little  avail.  In  cases  of  narrowing,  con- 
tinuous dilatation  may  bring  about  cure.  A  rigid  or  imperforate 
hymen,  adherent  labia,  or  mechanical  obstructions,  as  from  swellings 
or  tumors,  can  be  remedied  only  by  surgical  operation. 

Intromission  may  be  mechanically  possible,  but  may  be  resisted 
or  entirely  prevented  because  of  the  pain  occasioned  by  the  attempt. 
Thus,  acute  inflammations  about  the  vulva,  vagina,  uterus,  or  ovaries 
will  render  sexual  approach  extremely  painful ;  urethral  caruncles, 
urethritis,  fissures  of  the  neck  of  the  bladder,  hemorrhoids  or  rectal 
fissures,  ulcers  and  displacement  of  the  womb,  inflammation  of  the 
Fallopian  tubes,  and  disease  or  prolapse  of  the  ovaries,  are  frequently 
observed  as  causes  of  this  condition. 

Usually,  on  account  of  the  pain,  the  perineal  muscles  become 
spasmodically  contracted  and  intromission  is  impossible.  Sometimes 
this  spasm  does  not  occur  until  entrance  is  accompKshed,  in  which 
case  the  male  organ  may  be  so  tightly  imprisoned  that  release  is 
accomplished  only  when  the  muscles  of  the  female  are  relaxed  by 
ether.  It  is  customary  to  class  vaginismus  among  the  pure  neuroses. 
A  careful  search  will,  however,  in  almost  every  case  reveal  an  in- 
flammatory area  from  which  the  reflex  starts.  In  most  of  these  cases 
the  origin  of  the  reflexes  i^  to  be  found  in  fissures  in  the  neck  of  the 
bladder ;  urethral  caruncle  and  urethritis  are  also  frequent  causes  of 
vaginismus.  As  a  very  rare  exception  the  only  pathological  condition 
to  be  detected  is  an  apparently  causeless  hypersesthesia  of  the  vaginal 
mucous  membrane. 

The  treatment  of  vaginismus  depends  for  successful  issue  upon 
the  skill  and  thoroughness  with  which  local  examination  is  made. 
An  exhaustive  search  should  be  made  for  the  source  of  the  reflexes. 
In  the  absence  of  any  cause  discoverable  by  palpation  or  inspection 
of  the  genitalia,  a  thorough  endoscopic  examination  of  the  bladder 
must  be  made. 

The  cure  of  vaginismus  depends  upon  the  cure  of  its  exciting 
causes.  Where,  as  is  usually  the  case,  there  are  found  several  abnor- 
mal conditions,  each  of  which  may  possibly  be  responsible,  such  as 
extensive  fissure  in  ano,  chronic  endometritis,  and  granular  urethritis 
near  the  neck  of  the  bladder,  all  these  abnormal  conditions  should  be 
remedied. 


800  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

In  the  absence  of  any  local  pathological  condition,  vaginal  douches 
of  hot  one  per  cent,  soda  solution,  followed  by  the  application  of  ten 
per  cent,  cocaine  solution  to  the  vulva  and  the  lower  portion  of  the 
vagina,  may  render  introitus  comparatively  painless.  These  patients, 
belonging  as  they  do  to  a  neurotic  type,  should  receive  treatment 
appropriate  to  their  general  condition. 

STERILITY. 

Sterility  in  the  male  is  that  condition  in  which  there  is  loss  of 
procreative  power.  This  necessarily  implies  absence  of  living  sper- 
matozoa, since  these  are  the  elements  essential  to  impregnation,  but  it 
does  not  imply  failure  of  power  in  sexual  congress. 

Failure  to  bear  children  on  the  part  of  married  women  is  due  in  a 
certain  proportion  of  cases  to  sterility  of  the  husband.  The  definite 
percentage  cannot  be  given,  since  the  whole  subject  is  somewhat 
obscure.  Thus,  it  is  well  known  that  a  marriage  may  remain  barren, 
but  that  each  partner  of  this  marriage,  after  other  sexual  relations, 
may  become  a  parent.  The  percentage  of  sterile  husbands  in  childless 
marriages  has  been  variously  calculated  at  from  five  to  twenty. 

The  composition  and  physical  qualities  of  normal  semen  have 
been  already  described.  The  total  quantity  and  the  number  of 
spermatozoa  are  markedly  diminished  by  sexual  excess  and  wasting 
diseases.     Sterility  may  be  manifest  by — 

(1)  Aspermia,  entire  absence  of  semen. 

(2)  Oligospermia,  diminution  in  the  quantity  of  semen. 

(3)  Azoospermia,  absence  of  spermatozoa. 

Aspermia  is  a  condition  in  which  no  seminal  fluid  is  ejaculated, 
though  the  act  of  coitus  may  be  performed  normally  in  other  respects. 
Aspermia  may  be  due  to  imperfect  coordination  of  the  muscles  of 
ejaculation;  sometimes  it  is  an  expression  of  sexual  weakness.  In 
this  case,  though  there  is  no  escape  of  semen  during  orgasm,  it  may 
subsequently  drop  from  the  end  of  the  flaccid  penis. 

More  rarely  there  may  be  seminal  emissions  only  during  sleep,  pro- 
longed and  repeated  efforts  utterly  failing  to  produce  emission  during 
or  after  coitus.  In  this  case  incoordination  probably  involves  the 
muscles  which  force  the  seminal  fluid  into  the  prostatic  urethra 
and  the  dilatation  of  the  bulb,  or  failure  in  emission  may  be  due  to 
sensory  paralysis. 

As  a  modification  of  this  form  of  aspermia,  patients  are  seen  in 
whom  ejaculation  sometimes  takes  place  during  coitus  and  sometimes 
cannot  be  excited. 

The  common  cause  of  aspermia  is  obliteration  or  obstruction  of 


SEXUAL   WEAKNESS   AND   STEEILITY.  gQl 

some  portion  of  the  urethra.  This  obstruction  may  be  congenital  or 
acquired.  The  acquired  form  may  be  due  to  traumatism  or  inflam- 
mation. When  inflammation  has  attacked  and  destroyed  the  greater 
portion  of  the  secreting  substance  of  the  prostate,  and  has  blocked 
the  ejaculatory  ducts,  after  orgasm  there  will  be  a  discharge  of  two  or 
three  viscid  drops,  representing  the  secretion  of  Cowper's  glands  and 
the  urethral  crypts  and  follicles.  Tubercular  infiltration,  malignant 
degeneration,  the  pressure  of  tumors,  tight  stricture,  or  the  blocking 
of  the  passage  by  a  prostatic  or  cystic  calculus  may  produce  aspermia. 
Injury  to  the  common  ejaculatory  ducts,  without  involvement  of  the 
prostate,  will  cause  diminution  in  the  quantity  of  semen  secreted  and 
absence  of  spermatozoa,  but  not  aspermia,  since  the  prostatic  secre- 
tion is  ejaculated  and  presents  at  least  the  gross  physical  attributes 
of  normal  semen. 

The  term  false  aspermia,  or  malemission,  is  sometimes  employed 
to  designate  that  condition  in  which  semen  is  discharged  into  the 
urethra  but  does  not  reach  the  meatus,  either  passing  back  into  the 
bladder  to  be  voided  with  the  urine  or  exuding  drop  by  drop  from 
the  urethra  after  coitus  has  been  completed.  This  is  commonly  due 
to  stricture,  which  may  be  of  such  calibre  as  not  to  interfere  with  the 
function  of  micturition  when  the  circulation  of  the  parts  is  in  its  ordi- 
nary condition,  but  which  so  encroaches  upon  the  urethral  calibre  as 
the  result  of  congestion  incident  to  erection  that  the  passage  is  prac- 
tically obliterated.  Another  form  of  malemission  is  the  condition  in 
which  the  semen  is  not  properly  ejaculated  into  the  vagina  because 
of  some  defect  in  the  urethra,  such  as  hypospadia,  epispadia,  or 
urethral  fistulse.  Such  a  patient  is  neither  sterile  nor  impotent,  yet 
he  is  incapable  of  impregnation. 

Oligospermia,  or  a  diminution  in  the  quantity  of  semen  ejacu- 
lated, may  be  due  to  deficiency  in  quantity  or  absence  of  any  of  the 
constituent  parts  of  this  fluid.  Oligospermia  may  be  due  to  general 
weakness,  debilitating  disease,  sexual  neurasthenia,  sexual  excesses, 
masturbation,  or  any  of  the  various  inflammatory  or  infiltrating  affec- 
tions which  obliterate  the  ducts  of  the  glands  the  secretion  of  which 
goes  to  make  up  the  semen. 

Oligozo5spermia  indicates  a  condition  in  which  the  semen  ejacu- 
lated contains  few  spermatozoa. 

Azoospermia,  or  absence  of  spermatozoa  in  the  semen,  may  be  due 
to  absence  of  both  testes,  to  failure  of  the  testes  to  produce  sper- 
matozoa, or  to  mechanical  obstruction  in  some  portion  of  the  passage 
by  which  spermatozoa  reach  the  urethra.  The  testicles  fail  to  secrete 
spermatozoa  when  there  is  bilateral  retention,  atrophy,  or  malignant, 

51 


g02  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

syphilitic,  or  tubercular  degeneration.  Even  unilateral  affections  of 
the  testicles  frequently  cause  azoospermia.  Prolonged  exposure  of 
the  scrotum  to  the  x-ray  produces  oligonecrozoospermia  or  true  azo- 
ospermia.    The  latter  condition  is  common  in  Rontgen-ray  workers. 

The  ordinary  cause  is  bilateral  gonorrhoeal  epididymitis.  This  is 
followed  by  azoospermia  in  a  fairly  large  percentage  of  cases,  though 
•not  in  the  majority  of  those  carefully  treated.  The  obstruction  fol- 
lowing a  double  obliterating  gonorrhoeal  epididymitis  is  usually  placed 
in  the  tail  of  the  epididymitis,  but  healthy  spermatozoa  continue  to  be 
formed  in  the  testes  in  spite  of  the  obliteration.  Obstruction  of  the 
vasa,  either  congenital,  as  from  absence  or  occlusion,  or  acc|uired,  as 
from  traumatism  or  malignant  or  tubercular  degeneration,  or  blocking 
of  the  common  ejaculatory  ducts,  will  prevent  spermatozoa  from  reach- 
ing the  urethra.  Bilateral  blocking  of  the  ejaculatory  ducts  as  the 
result  of  chronic  gonorrhoeal  posterior  urethritis  is  not  uncommon,  but 
it  will  not  produce  aspermia,  since  it  simply  prevents  the  secretions 
of  the  seminal  vesicles  and  the  contents  of  the  ampullae  of  the  vasa 
from  being  discharged  into  the  urethra.  Sexual  excess  produces  tem- 
porary azoospermia. 

It  is  to  be  remembered  that  the  semen  discharged  by  those  suffer- 
ing from  azoospermia  may  be  normal  in  odor,  consistence,  and  primary 
gelatinification.  On  standing  the  white  deposit  is  thinner ;  on  micro- 
scopic examination  the  absence  of  spermatozoa  is  at  once  detected. 
This  semen  deposits  the  spermatic  (Bottcher)  crystals  very  rapidly. 

Alterations  in  the  color  of  the  semen  have  been  occasionally 
observed.  It  may  be  red  from  admixture  with  blood  due  to  inflam- 
mation or  intense  congestion  of  the  vesicles,  vasa,  or  prostatic  urethra. 
Unless  the  bleeding  has  been  recent,  the  color  will  be  a  dirty  choco- 
late. A  large  quantity  of  pus  mixed  with  the  semen  may  give  it  a 
yellowish  or  greenish  tint.  Indigo  is  sometimes  found  as  a  coloring 
matter,  and  is  said  to  impart  a  reddish  color  to  the  fluid  much  like 
that  due  to  admixture  with  blood. 

Treatment. — Sterility  dependent  upon  absence  or  imperfect  devel- 
opment of  any  portion  of  the  secreting  or  excreting  apparatus  is  in- 
curable. When  due  to  gonorrhoeal  epididymitis  of  comparatively 
recent  origin  it  usually  proves  amenable  to  the  treatment  described 
under  the  head  of  gonorrhoeal  epididymitis.  When  the  obstruction 
persists,  we  have  succeeded  in  relieving  it  by  performing  an  anasto-" 
mosis  between  the  vas  and  that  portion  of  the  epididymis  to  the  tes- 
ticular side  of  the  obstruction.  The  vas  lies  behind  the  spermatic 
artery,  which  sends  its  main  branches  forward  to  the  inner  side  of  the 
epididymis,  anastomosing  freely  at  this  point  with  the  artery  of  the 


SEXUAL   WEAKNESS   AND   STEEILITY. 


803 


vas.  The  epididymis  is  approached  from  its  outer  side.  A  portion 
of  the  head  is  picked  up  in  toothed  forceps  and  excised.  If  this 
excision  is  made  on  the  testicular  side  of  the  obstruction  there  will 
ooze  from  the  wound,  semen  which  contains  motile  spermatozoa.  The 
lumen  of  the  vas  is  opened  by  a  longitudinal  cut  one-c{uarter  of  an 
inch  long.  Into  this  wound  of  the  epididymis  the  vas  is  implanted  by 
means  of  four  fine  silver-wire  sutures,  carried  on  small  face  needles 


Fig.  254. 


\ 


I      Ws       f^.^.-^ 


\ 


1^ 


Anastomosis  between  the  vas  deferens  and  the  head  of  the  epididymis. 


from  the  outer  surface  of  the  vas  into  its  lumen  ;  thence  from  the  cut 
surface  of  the  opening  made  into  the  epididymis  through  its  fibrous 
tunic.  (Fig.  254.)  Because  of  the  smallness  of  the  structures  in- 
volved, the  operation  is  tedious  rather  than  difficult.  Aside  from  the 
ordinary  surgical  mstruments,  there  will  be  needed  a  sharp-pointed 
pair  of  scissors,  a  slender  bistoury,  and  a  grooved  director,  such  aa 
are  used  by  ophthalmologists. 


804  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

When  the  sterility  is  dependent  upon  blocking  of  the  common 
ejaculatorj'-  duct,  no  treatment  has  been  suggested  which  promises 
favorable  results.  Sterility  dependent  upon  stricture  is  cured  by  full 
dilatation  of  the  urethra.  If  due  to  muscular  incoordination,  tonic  or 
stimulant  treatment  directed  to  the  general  nervous  condition  may 
be  beneficial.  That  form  of  sterility  which  is  apparently  dependent 
upon  chronic  suppuration  of  the  prostatic  urethra,  ejaculatory  ducts, 
seminal  vesicles,  and  ampullge  of  the  vasa  is  best  treated  by  massage, 
combined  with  unirritating  antiseptic  urethral  irrigations. 


CHAPTER   XXII. 

PSYCHOPATHIA    SEXUALIS. 

The  various  forms  of  perversion  or  aberration  of  the  sexual  instinct 
are,  as  a  rule,  associated  with  symptoms  w^hich  belong  to  the  domain 
of  the  neurologist  or  the  alienist.  But  some  of  them  have  a  physical 
basis  which  demands  attention  from  the  genito-urinary  specialist,  who 
is,  at  any  rate,  apt  to  be  first  consulted  in  many  such  cases.  Moreover, 
the  distinction  between  a  pure  neurosis  and  one  dependent  upon  lesions 
often  requires  the  judgment  of  an  expert,  based  upon  a  thorough  ex- 
amination of  the  genital  t^-act.  It  seems  proper,  therefore,  to  present 
a  brief  summary  of  the  chief  varieties,  and  to  give  at  least  a  r^um^  of 
the  general  principles  which  should  apply  in  dealing  with  these 
patients.  The  works  of  Krafft-Ebing  and  Schrenck-Notzing  are  the 
most  valuable  of  recent  contributions  to  this  subject,  and  have  been 
used  freely  in  the  preparation  of  this  chapter. 

An  accurate  and  entirely  scientific  classification  of  these  phenom- 
ena is  at  present  impossible,  but  a  provisional  one  may  be  employed, 
which  will  aid  in  the  systematic  study  of  the  subject. 

Nearly  all  the  known  varieties  of  sexual  perversion  will  fall  under 
one  or  other  of  the  following  headings : 

A.  Sexual  Hyperesthesia. 

1.  Onanism, 
(  Satyriasis. 
\  Nymphomania. 

B.  Sexual  Anesthesia. 

Impotence.     (See  Chapter  XXI.) 
•   C.  Sexual  Paresthesia. 

1.  Heterosexual  perversion,— algolagnia.      Perverse  activity 

of  the  sexual  impulse. 

2.  Inversion  of  the  sexual  feeling  (contrary  sexual  feeling ; 

homosexuality,  etc.). 
Sexual  hyperaesthesia,  when  not  dependent  on  affections  of 
the  cord  or  on  cervical  disease,  is  usually  associated  with  hyper- 
aesthesia of  the  deep  urethra.  This  in  its  turn  may  be  caused  by 
masturbation  when  practised  in  great  excess,  by  urethral  stricture, 
by  sexual  intemperance  (which  term  should  include  both  excessive 

805 


806  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

intercourse  and  prolonged  abstinence),  by  departure  from  the  normal 
or  physiological  in  the  performance  of  the  act  of  copulation  (as,  for 
example,  the  practice  of  withdrawal  for  the  prevention  of  conception), 
and  in  various  other  ways.  Certain  drugs  produce  it,  cantharides 
being  the  best  known. 

Onanism  is  the  most  wide-spread  of  these  causes,  a  majority  of 
males  having  at  some  time  in  their  lives  practised  it.  Much  difference 
of  opinion  prevails  even  in  the  profession  as  to  its  exact  importance 
as  a  cause  of  cerebral  or  spinal  disease. 

Its  alleged  consequences  are  used  by  quacks  to  foster  the  miseries 
of  the  sexual  hypochondriac,  who,  having  almost  always  been  a  mas- 
turbator  to  some  extent  during  his  youth,  is  easily  led  to  beheve  that 
he  has  thus  done  himself  serious  injury.  It  is  thought,  however,  by 
many  practitioners  that,  apart  from  the  question  of  morality,  the  effect 
of  the  act  itself  on  the  nervous  system  is  injurious.  Von  Schrenck- 
Notzing,  in  reply  to  the  argument  that  the  single  act  of  masturbation 
is  no  more  harmful  than  that  of  normal  coitus,  says  that  masturbation 
has  a  much  more  intense  psychical  effect  than  sexual  intercourse, 
as  the  content  of  ideas  in  every  onanistic  act  must  overcome  reality, 
and  thus  a  much  more  intense  strain  of  the  imagination  is  neces- 
sary. He  adds,  however,  that  "  masturbation  moderately  practised 
exercises  on  a  good  constitution  no  direct  destroying  effect,  but  it 
changes,  when  it  is  long  indulged  in,  the  character,  the  imagination, 
and  the  whole  mental  existence  in  a  way  that  is  unmistakable  and,  so 
to  speak,  necessary.  These  evil  effects  of  onanism  seem  to  us  to  be 
greater  than  those  lesser  disturbances  which  seldom  affect  materially 
the  general  health." 

A  long  list  of  local  disorders  following  excesses  in  onanism  is  to-be 
found  in  the  abundant  literature  of  the  subject.  Lowenfeld  (quoted 
by  Schrenck-Notzing)  says  that  in  the  male  the  most  frequent  results 
are  "  excessive  pollutions  (day  and  night),  spermatorrhoea,  premature 
ejaculation  in  attempt  at  coitus,  hypersesthesia  of  the  genital  centres, 
spinal  neurasthenia,  congestion  of  the  prostate,  inflammation  of  the 
urethra,  hypersemia  and  swelling  of  the  mucous  membranes,  and  in- 
tense sensitiveness  of  the  glans.  In  young  children,  besides,  there 
may  readily  occur  vesical  tenesmus,  wetting  of  the  bed,  spasm  of  the 
compressor  urethrae,  and  urinary  incontinence."  Further  results  are 
urethritis,  prostatorrhoea,  spermatorrhoea,  and  impotence.  As  sec- 
ondary results  of  the  neurosis  of  the  lumbar  portion  of  the  cord  he 
mentions  "  general  neurasthenia,  tachyc'ardia,  pains  in  the  eyelids, 
spasm  of  the  lids,  photophobia,  or  subjective  sensations  of  light, 
diminution  of  the  acuity  of  central  vision,  neurasthenic  asthenopia." 


PSYCHOPATHIA   SEXUALIS.  807 

In  the  female  masturbation  is  said  to  produce  neurasthenic  dis- 
turbances, such  as  hysterical  attacks,  paralyses  (vesical  paralysis), 
vesical  tenesmus  and  spasm,  ovarian  neuralgia,  weakness  of  the  legs, 
and  spinal  irritation.  Among  alleged  local  disturbances  may  be 
mentioned  hypersemia  of  the  labia  minora  and  the  vaginal  orifice, 
desquamation  of  the  vaginal  epithehum,  fluor  albus,  cervical  catarrh, 
intense  hypersesthesia,  pruritus  vulvae,  hypertrophy  of  the  clitoris, 
and  irritable  conditions  of  the  uterus  and  adnexa.  Schrenck-Notzing 
says  that  "  a  condition  that  has  thus  far  been  too  little  studied,  and 
which  in  its  significance  is  one  of  the  most  important  and  frequent 
results  of  masturbation  in  the  female,  is  a  form  of  impotence  in 
which  the  orgasm  no  longer  occurs  during  the  sexual  act,  even  when 
it  is  performed  with  several  men,  but  in  many  cases  may  be  induced 
post  coitum  by  masturbation." 

It  is  not  possible  here  to  go  into  this  subject  with  detail,  but  it 
seems  to  us  that  in  both  sexes  the  act  of  masturbation,  while  unques- 
tionably exercising  a  prejudicial  influence  on  the  general  character  on 
account  of  the  sense  of  wrong-doing  almost  invariably  accompanying 
it  and  the  atmosphere  of  secrecy  and  deceit  which  necessarily  sur- 
rounds it,  cannot  in  normal  individuals  be  accredited  with  more  than 
a  very  small  proportion  of  the  evils  said  to  follow  in  its  wake. 

In  neuropathic  children  or  adolescents,  the  inheritors  of  de- 
praved nervous  systems  or  of  vicious  impulses,  it  is  no  doubt  far 
more  injurious,  but  even  in  them  it  is  open  to  question  whether  it  is 
a  cause  or  a  symptom  of  the  associated  nervous  phenomena.  An 
exhaustive  investigation  was  made  by  one  of  the  writers  some  years 
ago  into  its  relation  to  hereditary  nervous  and  mental  disease  as 
seen  among  criminals.  The  result  showed  that  the  men  who  had 
become  onanists  in  a  criminal  population  of  eight  hundred  were 
classified  either  as  the  subjects  of  mental  or  physical  disease  at  the 
time  of  their  admission  to  prison  or  as  hereditarily  predisposed  to 
such  disease  in  the  proportion  of  eighty-five  per  cent.  Among  the 
remainder  of  the  eight  hundred  only  fifty-eight  per  cent,  were  so 
classified.  So,  too,  it  was  found  that  fifty-six  per  cent,  of  the  mas- 
turbators  had  been  guilty  of  one  or  another  of  the  so-called  "  crimes 
of  the  passions," — as  distinguished  from  crimes  against  property, — 
while  a  review  of  the  records  for  fifty  years  showed  that  only  thir- 
teen per  cent,  of  the  whole  number  of  convicts  had  been  convicted 
for  crimes  of  this  character.  The  evidence,  therefore,  goes  to  show 
that  masturbation  in  great  excess  is  itself  a  symptom  rather  than  a 
cause  of  the  various  nervous  phenomena  attributed  to  it. 

As  to  the  ordinary  form  of  masturbation,  so  common  as  almost 


gOg  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

to  be  called  physiological,  the  views  of  Sir  James  Paget  seem  to  us  to 
be  wholly  correct.  He  said  twenty-five  years  ago  that  he  beheved 
"  you  may  teach  positively  that  masturbation  does  neither  more  nor 
less  harm  than  sexual  intercourse  practised  with  the  same  frequency 
with  the  same  conditions  of  general  health  and  age  and  circum- 
stance. Practised  frequently  by  the  very  young, — that  is,  at  any 
time  before  or  at  the  beginning  of  puberty, — masturbation  is  very 
likely  to  produce  exhaustion,  effeminacy,  over-sensitiveness,  and 
nervousness,  just  as  equally  frequent  copulation  at  the  same  age 
would  probably  produce  them.  Or,  practised  every  day,  or  many 
times  in  one  day,  at  any  age,  either  masturbation  or  copulation  is 
likely  to  produce  similar  mischiefs  or  greater.  And  the  mischiefs  are 
especially  likely  or  nearly  sure  to  happen,  and  to  be  greatest,  if  the 
excesses  are  practised  by  those  who,  by  inheritance  or  circumstances, 
are  liable  to  any  nervous  disease,  to  '  spinal  irritation,'  epilepsy, 
insanity,  or  any  other  neurosis.  But  the  mischiefs  are  due  to  the 
quantity,  not  to  the  method,  of  the  excesses ;  and  the  quantity  is  to 
be  estimated  in  relation  to  age  and  the  power  of  the  nervous  system. 
He  has  seen  as  numerous  and  as  great  evils  consequent  on  excessive 
sexual  intercourse  as  on  excessive  masturbation  ;  but  he  has  not 
seen  or  heard  anything  to  make  him  believe  that  occasional  mastur- 
bation has  any  other  effects  on  one  who  practises  it  than  has  occa- 
sional sexual  intercourse,  or  anything  justifying  the  dread  with  which 
sexual  hypochondriacs  regard  the  having  occasionally  practised  it." 

Treatment  of  Onanism  in  Childi^en. — In  the  absence  of  inherited 
neuropathy,  onanism  in  very  young  children  is  usuaUy  an  automatic 
act,  resulting  from  some  persistent  local  irritation. 

Phimosis,  balanitis,  vesical  calculus,  and  urethral  polyp  are  com- 
mon causes  of  sexual  excitation  in  male  children,  producing  the 
custom  of  handling  or  pulling  at  the  penis,  which  after  a  time  results 
in  a  fully  formed  onanistic  habit. 

Masturbation  in  young  female  children  is  far  less  common  than  in 
males.  Eczema  and  pruritus  vulvae,  seat-worms,  and  other  causes  of 
irritation  about  the  genitals  or  the  anus  are  the  most  common  etio- 
logical factors. 

In  both  sexes  irritation  from  diapers  or  from  tightly  fitting  clothing 
may  favor  the  continuance  of  the  habit. 

Obviously  the  treatment  of  such  cases  is  to  be  directed  towards 
the  removal  of  the  cause.  Circumcision  should  be  performed,  re- 
gardless of  the  condition  of  the  foreskin,  in  all  children  who  have 
this  habit. 

Even  if  it  is  not  very  long  or  tightly  adherent,  its  removal  lessens 


PSYCHOPATHIA   SEXUALIS.  809 

the  sensitiveness  of  the  region  of  the  glans  and  the  fraenum.  The 
psychical  effect  of  the  operation  itself,  if  the  child  is  three  or  four 
years  of  age  or  older,  has  a  powerful  deterrent  influence.  Of  course 
vesical  calculi  should  be  removed,  eczema  cured,  and  the  other 
pathological  conditions  mentioned  should  receive  appropriate  treat- 
ment. 

Intelligent  parents  can  be  of  great  assistance  in  breaking  up  the 
habit.  The  individual  management  of  the  child  must  be  determined 
by  his  peculiarities  of  disposition  and  temperament.  With  some  chil- 
dren, even  while  they  are  very  young,  a  few  words  of  caution  or  advice 
are  effectual.  With  others  some  form  of  punishment  is  required. 
Occasionally  it  may  be  necessary  to  apply  a  vesicant  to  the  genitals, 
so  as  to  leave  a  denuded  spot  which  will  be  painful  enough  to  prevent 
handling  of  the  part. 

Attention  should  be  paid  to  the  condition  of  the  urine.  An  excess 
of  uric  acid,  oxaluria,  a  very  acid  or  concentrated  urine,  may  furnish 
the  necessary  stimulus  to  the  performance  of  the  act. 

The  diet,  especially  the  evening  meal,  should  be  light  and  simple. 
Constipation  should  be  carefully  avoided.  An  enema  of  cold  water 
at  bedtime,  followed  by  the  insertion  of  a  white  wheat  gluten  sup- 
pository into  the  rectum,  will  often  be  found  of  advantage. 

Open-air  exercise  to  the  point  of  fatigue  is  indicated  in  the 
majority  of  cases.     Drugs  should  be  avoided. 

Treatment  of  Onanism  in  Adolescents  and  Adults. — In  all  cases  of 
persistent  masturbation,  at  whatever  age,  the  same  general  line  of 
treatment  as  that  outlined  above  should  be  followed.  The  condi- 
tions that  are  provocative  of  the  act  in  young  children  may  cause  its 
continuance  after  puberty.  In  males  circumcision  is  especially  to  be 
recommended,  the  patient  being  told  that  the  operation  is  necessitated 
by  his  previous  indulgence  in  the  vice,  and  that  it  will  prove  curative. 
Cold  bathing,  a  simple  natural  life,  a  plain  diet,  plenty  of  exercise,  and 
avoidance  of  social  and,  of  course,  of  sexual  excitements,  are  the  main 
points  to  be  observed  as  to  the  hygiene  of  such  patients. 

The  use  of  full-sized  cold  steel  sounds  introduced  twice  weekly, 
and  left  in  the  urethra  for  from  ten  to  fifteen  minutes,  instillations  of 
fifteen  to  twenty  drops  of  a  one  per  cent,  silver  nitrate  solution  into 
the  prostatic  urethra,  and  counter-irritation  to  the  perineum,  are  the 
chief  therapeutic  measures. 

As  to  the  general  advice  to  be  given  such  patients  in  regard  to 
their  sexual  relations,  while  we  agree  with  those  who  think  it  improper 
to  advise  fornication,  and  believe  it  is  almost  equally  inadvisable  to 
recommend  marriage  as  a  mode  of  treatment,  yet  we  must  dissent 


810  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

from  the  opinions  which  have  been  expressed  by  many  of  the  most 
distinguished  men  in  the  profession  as  to  the  harmlessness  of  enforced 
chastity.  Sexual  abstinence,  when  entirely  voluntary  and  spontane- 
ous, and  practised  without,  thought  or  mental  struggle  on  the  part  of 
the  patient,  is  doubtless  harmless.  But  it  seems  to  us  equally  beyond 
doubt  that  the  continence  which  is  the  result  of  fear  of  wrong-doing 
or  of  dread  of  social  disgrace  or  of  physical  disease,  and  which  is  at- 
tended with  continued  sexual  excitation  and  constant  hypersemia  of 
the  genital  organs,  is  harmful.  We  believe  that  every-day  clinical 
facts  abundantly  demonstrate  the  truth  of  this  assertion,  if  they  are 
studied  without  prejudice  or  preconceived  theory.  It  does  not  follow 
that  a  remedy  can  be  suggested.  It  is  highly  probable  that  the  evils 
which  certainly  result  from  continence  in  some  individual  cases  are 
far  less  than  those  which  would  result  from  promulgation  of  the  doc- 
trine that  "  the  idea  of  complete  health  includes  complete  and  regular 
satisfaction  of  all  the  needs  of  man,  and  that  is  the  goal  for  which 
hygiene  must  strive,  and  not  seek  to  stifle  one  of  the  most  important 
functions  of  the  organism,  like  the  sexual  instinct.  The  recommen- 
dation voluntarily  to  destroy  any  function  like  the  idea  of  love  is  a 
subject  for  the  fanatic,  but  directly  opposed  to  hygiene."  (Tar- 
nowsky.) 

Von  Schrenck-Notzing,  writing  of  prostitution,  says,  "  The  limita- 
tion of  the  evil  to  a  minimum,  which  seems  to  every  one  of  any 
knowledg'e  of  the  subject  both  desirable  and  attainable,  with  any 
prospect  of  relative  success,  can  only  be  brought  about  through  an 
inner  reform  of  society  ;  through  correct  education  of  the  young  and 
ignorant ;  and  through  an  increase  of  facility  of  marriage  and  amelio- 
ration of  conditions  of  life.  '  For  the  more  undeveloped  an  indi- 
vidual is,  the  more  reckless  he  is  in  the  gratification  of  his  desires.' 
We  should  institute  a  real  sexual  education,  and  lead  the  matured 
sexual  instinct  by  means  of  the  preservation  of  rational  indulgence 
into  paths  devoid  cf  danger ;  we  should  make  needful  concession  to 
the  natural  impulse ;  and  thus  public  vice,  with  its  results,  the  un- 
limited spread  of  venereal  diseases  and  the  increasing  number  of 
crimes  against  morality,  would  be  greatly  diminished  and  become 
more  and  more  confined  to  the  step-children  of  nature  (those  subject 
to  congenital  viciousness).  But,  more  than  all,  the  foundation  would 
be  removed  upon  which  rest  masturbation  and  the  development  of 
the  sexual  instinct  in  perverse  directions." 

Continuing,  he  adds,  "  The  strength  and  intensity  of  the  sexual 
instinct,  like  moral  and  physical  individuality,  are  too  various  to  make 
it  necessary  to  give  a  general  application  to  the  foregoing  statements. 


PSYCHOPATHIA   SEXUALIS.  gH 

Such  a  misunderstanding  might  become  a  welcome  license  and  cloak 
for  all  possible  expression  of  vice,  and  it  would  open  the  door  to 
sensuality.  While  one,  thanks  to  the  inherent  peculiarities  of  his 
organization,  can  easily  practise  abstinence,  another  is  led  to  onan- 
ism, and,  as  a  result  of  it,  is  utterly  ruined  if  he  has  no  opportunity 
for  natural  sexual  indulgence." 

We  believe,  as  we  have  already  said,  that  the  patients  "  utterly 
ruined"  by  onanism  are  very  few,  but  it  must  be  admitted  that  even 
in  the  cases  in  which  it  is  a  symptom  rather  than  a  cause  of  disease 
normal  sexual  relations  are  greatly  to  be  desired  for  the  patient. 

In  the  present  constitution  of  society  individuals  must  suffer.  We 
cannot  follow  either  in  theory  or  in  practice  the  further  teaching  of 
Notzing,  who  says,  "The  chaste  youth  should  exercise  sexual  absti- 
nence as  long  as  he  is  able  to  restrain  the  instinct  without  injury  to 
his  health.  Should  he  be  in  danger,  owing  to  increasing  strength  of 
his  sexual  impulse,  of  onanism,  of  falling  a  victim  to  satyriasis  or 
perverse  sexual  indulgence,  then  it  becomes  the  duty  of  his  teacher 
and  his  physician  to  cause  indulgence  in  coitus,  and  also  to  acquaint 
the  neophyte  with  precautionary  measures  which  will  guard  against 
excesses,  infection,  and  the  procreation  of  illegitimate  offspring,  which, 
under  certain  circumstances, — e.g.^  with  contrary  sexuality, — may  be 
hereditarily  tainted.  Individual  sexual  capabilities  should  determine 
the  frequency  of  sexual  indulgence.  It  is  impossible  to  fix  a  normal 
standard." 

We  do  not  believe  that  it  is  customary  in  this  country  to  give 
advice  of  this  character,  and  we  think  the  resultant  evils,  if  this  should 
become  a  common  professional  practice,  would  far  outweigh  the  ad- 
vantages, but  we  must  reiterate  that  the  contrary  teaching  as  to  the 
invariable  harmlessness  and  even  benefit  of  sexual  continence  is  un- 
scientific, and  is  opposed  to  many  easily  observed  clinical  phenomena. 

Satyriasis  and  Nymphomania. — In  these  cases  the  sexual  de- 
sire is  so  overpowering  that  its  gratification  becomes  the  one  dorriinant 
thought  and  purpose  of  the  patient's  life.  The  condition  may  be  spas- 
modic w^ith  remissions,  or,  in  bad  cases,  may  be  almost  continuous. 
It  is  favored  by  any  form  of  genital  irritation,  but  the  essential  factor 
is  some  cerebral  disturbance  or  degeneration  which  results  in  a  dimi- 
nution or  abolition  of  the  will-power.  Magnan  locates  these  lesions 
i-i  the  sensory  regions  of  the  cortex  which  lie  behind  the  central  con- 
volutions, where,  according  to  this  author,  "  the  zone  of  the  desires 
and  instincts  lies,  and  which  are  influenced  quasi-automatically  by  the 
genito-spinal  centre  as  soon  as  the  forebrain  for  any  reason  ceayes  to 
act." 


yi2  GENITO-UEINARY    DISEASES   AND    SYPHILIS. 

It  may  in  some  cases  be  a  reversion  to  ancestral  instincts.  In 
many  of  the  lower  animals  during  the  rutting  season  the  sexual  im- 
pulse becomes  so  powerful  as  to  dominate  all  other  desires  and  habits 
and  render  the  individual  insensible  to  dangers  ordinarily  carefully 
avoided. 

Women  are  said  to  be  more  subject  to  this  form  of  sexual  perver- 
sion than  are  men.  Whether  this  is  true  or  not,  there  can  be  no 
doubt  that,  since  women  have  less  sexual  need  than  men,  a  predom- 
inating sexual  desire  in  them  should  arouse  more  early  a  suspicion 
of  its  having  some  pathological  significance. 

Krafft-Ebing  says  that  "the  central  origin  of  sexual  oxcitement 
is  of  frequent  occurrence  in  persons  having  a  neurotic  taint  or  hys- 
teria, and  in  conditions  of  psychical  exaltation.  Here,  where  the  cor- 
tex and  the  psycho-sexual  centre  are  in  a  condition  of  hypersesthesia 
(abnormal  excitability  of  the  imagination,  increased  ease  of  associa- 
tion), not  only  visual  and  tactile  impressions,  but  also  auditory  and 
olfactory  sensations,  may  be  sufficient  to  call  up  lascivious  concepts." 

Magnan  {op.  cit.)  reports  the  case  of  a  young  woman  who  had  an 
increasing  sexual  desire  from  puberty,  and  satisfied  it  by  masturba- 
tion. Gradually  she  grew  to  become  sexually  excited  at  the  sight  of 
any  man  pleasing  to  her,  and,  since  she  was  unable  to  control  herself, 
she  would  sometimes  shut  herself  up  in  a  room  until  the  storm  had 
passed.  At  last  she  gave  herself  up  to  men  of  her  choice,  that  she 
might  get  rest  from  her  tormenting  desire ;  but  neither  coitus  nor 
masturbation  brought  relief,  and  she  went  to  an  asylum. 

The  case  is  added  of  a  mother  of  five  children,  who,  in  despair 
about  her  inordinate  sexual  impulse,  attempted  suicide,  and  then 
sought  an  asylum.  There  her  condition  improved,  but  she  never 
trusted  herself  to  leave  it. 

It  is  obvious  that  in  such  patients  the  sexual  symptoms  are  only 
part  of  a  general  disease,  probably  cerebral  in  almost  every  instance. 

They  are  acute  manifestations  of  a  more  or  less  chronic  degenera- 
tive process,  which  later  will  nearly  always  show  itself  by  some  form 
of  paresis  or  paralysis,  or  by  mania  or  dementia. 

Krafft-Ebing  says,  "  There  are  also  cases  that,  not  without  reason, 
might  be  called  chronic  satyriasis  or  nymphomania.  To  these  belong 
the  men  who,  for  the  most  part  as  a  result  of  abusus  veneris,  or  more 
particularly  of  masturbation,  suffer  with  neurasthenia  sexualis,  and  at 
the  same  time  have  intense  libido  sexualis.  The  imagination,  as  in 
acute  cases,  is  in  a  state  of  excitement  and  the  mind  full  of  obscene 
images,  so  that  the  most  elevated  ideas  are  besmirched  with  the  most 
cynical  images  and  thoughts.    The  thought  and  desire  of  such  men  are 


PSYCHOPATHIA   SEXUALIS.  813 

solely  directed  to  the  sexual  sphere  ;  and  since  their  flesh  is  weak,  led 
on  by  their  fancy,  they  come  to  indulge  in  the  grossest  perversions  of 
the  sexual  act.  Analogous  cases  in  women  may  be  called  chronic 
nymphomania.     They  naturally  lead  to  prostitution." 

In  all  these  cases  the  genito-urinary  surgeon  may  be  of  use  in 
removing  every  source  of  peripheral  irritation,  an  important  element 
of  treatment,  as  it  renders  more  easy  a  restoration  of  the  balance 
between  desire  and  will-power. 

Sexual  AnsBSthesia. — The  ordinary  forms  of  impotence,  or  in- 
ability to  perform  the  sexual  act,  in  the  male  are  among  the  manifes- 
tations of  sexual  anaesthesia,  and  are  described  in  Chapter  XXI. 

The  corresponding  forms  of  impotence  in  women  are  less  frequent, 
so  far  as  the  profession  has  any  reliable  knowledge  of  the  subject. 
The  most  common  variety  is  said  to  be  that  in  which  failure  of  the 
female  to  secure  orgasm  during  the  sexual  act  is  owing  to  premature 
ejaculation  on  the  part  of  the  male, — premature,  that  is,  in  relation  to 
the  woman's  requirements.  This  appears  to  be  due  in  a  large  propor- 
tion of  cases  to  a  degree  of  sexual  coldness  which  is  not  overcome  by 
the  ordinary  mechanical  excitation  of  the  parts,  and  may  result  from 
either  physical  or  psychical  conditions. 

Among  the  former  is  to  be  noted  disproportion  between  the 
genital  organs  of  the  two  individuals,  as  in  cases  of  abnormally  small 
development  on  the  part  of  the  male  or  of  unusually  large  and  re- 
laxed genitalia  on  that  of  the  female.  Exhaustion  of  the  sexual  centre 
from  long-continued  uterine  or  ovarian  irritation,  neurasthenia,  and 
vaginismus  should  also  be  mentioned.  Emotional  conditions  are 
among  the  chief  psychical  causes  of  impotence  in  the  female, — the 
fear  of  pregnancy,  or  of  disease,  or  of  discovery,  when  the  intercourse 
is  illegitimate  ;  the  lack  of  affection,  or  of  some  of  the  sentimental 
concomitants  of  the  act,  when  it  is  performed  maritally. 

It  is  obvious  that  in  the  management  of  these  cases  the  tact  and 
intimate  personal  knowledge  of  the  regular  medical  attendant  are 
likely  to  be  of  far  more  u?e  than  any  surgical  or  gynaecological  pro- 
cedures, which  must  be  limited  to  the  removal  of  obvious  sources 
of  irritation  and  of  any  mechanical  impediments  to  intercourse. 

The  foregoing  conditions  barely  fall  within  the  hmits  of  sexual 
psychopathy,  but  there  are  more  marked  examples  of  sexual  anaesthe- 
sia in  both  sexes  in  which  the  absence  of  sexual  instinct  seems  to  be 
absolute  and  to  depend  upon  central  causes. 

Krafft-Ebing  says  that  these  functionally  sexless  individuals  are 
seldom  seen,  and  are,  indeed,  always  persons  having  degenerative 
defects,  and  in  whom  other  functional  cerebral  disturbances,  states  of 


gl4  GENITO-URINAPvY   DISEASES   AXD   SYPHILIS. 

psychical  degeneration,  and  even  anatomical  signs  of  degeneration, 
are  observed.  With  such  patients  there  is  even  less  opportunity  for 
treatment,  which  should  in  any  event  be  directed  by  the  neurologist 
or  alienist. 

Sexual  Paresthesia. — In  all  its  forms  this  condit'on  involves  a 
perversion  of  the  sexual  ideas  with  relation  to  the  individual.  The 
perversion  may  be — 1,  heterosexual,  with  abnormal  and  distorted 
activity  of  the  sexual  impulse,  or,  2,  homosexual. 

1.  Algolagnia  {algos,  pain ;  lagnos,  lust). — In  the  heterosexual 
varieties  of  the  disease — i.e.,  those  in  which  an  inclination  to  inter- 
course with  the  opposite  sex  exists — the  perversion  may  take  the 
form  of  associating  acts  of  cruelty  and  violence  with  the  act  of  coitus. 
When  such  acts  are  directed  by  the  patient  against  another  person 
the  disease  is  known  as  sadism  (active  algolagnia).  This  is  not  infre- 
quent, especially  with  males.  It  is  explained  on  the  theory  that  the 
two  emotions  of  lust  and  anger  both  throw  the  psychomotor  sphere 
into  a  state  of  extreme  excitation,  causing  an  impulse  to  react  in 
every  possible  way  on  the  object  that  supphes  the  stimulus.  In 
neuropathic  individuals  this  impulse  becomes  uncontrollable  and 
leads  to  mutilation  or  murder.  The  disease  is  more  frequent  in  males 
because  to  them  belongs  the  aggressive  role  in  sexual  life,  and  their 
sexual  relations  have  always  involved  the  overcoming  of  obstacles. 
In  the  presence  of  pathological  conditions  this  aggressiveness,  usually 
physiological,  becomes  uncontrollable  and  leads  to  various  monstrous 
and  unnatural  crimes. 

The  Whitechapel  murderer  is  in  ah  probability  an  example  of  the 
most  extreme  form  of  sadism.  A  minor  form  is  illustrated  by  one  of 
Tarnowsky's  cases.  The  patient  was  a  physician  of  neuropathic 
constitution  reacting  badly  to  alcohol.  Under  ordinary  circumstances 
capable  of  normal  coitus,  as  soon  as  he  indulged  in  wine  he  found 
that  his  increased  desire  was  no  longer  satisfied  by  simple  coitus.  In 
this  condition  he  was  compelled  to  prick  the  nates  puellse  or  to  make 
stabs  with  the  lancet,  to  see  blood  and  feel  the  entrance  of  the  blade 
into  the  living  body,  in  order  to  have  ejaculation  and  experience 
complete  satiety  of  his  lust. 

Cases  exemplifying  a  great  variety  of  forms  of  sadism  have  been 
published  in  detail,  but  it  is  probable  that  they  differ  only  in  degree 
from  those  in  which  the  abnormal  impulse  is  satisfied  by  biting, 
scratching,  or  light  flagellation  to  those  in  which  the  patient  becomes 
a  veritable  monster,  sucking  the  blood  or  eating  the  flesh  of  his 
victim. 

Masochism  (passive  algolagnia)  is  the  converse  of  sadism.     The 


PSYCHOPATHIA   SEXUALIS.  815 

abnormality  manifests  itself  in  a  desire  to  suffer  and  be  subjected 
to  violence  and  cruelty.  It  might  be  expected  that  for  similar  physi- 
ological reasons  to  those  which  explain  the  greater  frequency  of 
sadism  in  males,  masochism  would  be  found  far  more  frequently  in 
females,  whose  normal  instincts  lead  towards  sexual  subjugation  and 
submission.  But  except  in  very  rare  instances  the  restraints  of  cus- 
tom and  of  modesty  have  been  sufficient  to  prevent  women  from 
giving  noticeable  expression  to  this  form  of  sexual  perversion,  which 
probably  often  constitutes  an  unobserved  stage  of  mental  disorder 
shown  later  in  other  ways. 

In  men  masochism  is  frequent,  large  numbers  of  cases  having 
been  reported  in  great  detail.  It  is  usually  less  serious  in  its  conse- 
quences than  is  sadism. 

"  In  masochism  there  is  also  a  gradation  of  the  acts  from  the  most 
repulsive  and  monstrous  to  the  silliest,  in  accordance  with  the  degree 
of  intensity  of  the  perverse  instinct,  and  the  power  of  the  remnants 
of  moral  and  aesthetic  motives  that  oppose  it.  The  ultimate  conse- 
quences of  masochism,  however,  are  opposed  by  the  instinct  of  self- 
preservation,  and  therefore  murder  and  serious  injury,  which  may  be 
committed  in  sadistic  excitement,  have  here,  as  far  as  known,  no 
passive  equivalent  in  reahty ;  but  the  perverse  desires  of  masochistic 
individuals  may,  in  imagination,  attain  these  extreme  consequences." 
(Krafft-Ebing.) 

For  example  we  may  cite  the  case  of  a  middle-aged  man,  married, 
and  the  father  of  a  family,  who  had  always  led  a  normal  sexual  life, 
but  who  came  of  a  very  nervous  family.  In  his  early  youth  he  was 
powerfully  excited  sexually  at  the  sight  of  a  woman  slaughtering  an 
animal  with  a  knife.  From  that  time,  for  many  years,  he  revelled  in 
the  lustfully  colored  idea  of  being  stabbed  and  cut  and  even  killed  by 
women  with  knives.  Later,  after  the  beginning  of  normal  sexual 
intercourse,  these  ideas  lost  completely  their  perverse  stimulus  for 
him. 

Rousseau  appears  to  have  been  a  masochist,  and,  according  to 
Lombroso,  Baudelaire  belonged  in  the  same  class. 

2.  Homosexuality,  or  contrary  sexual  instinct,  is  a  form  of  sexual 
paraesthesia  which  is  among  those  most  commonly  observed.  A  large 
number  of  varieties  have  been  noted  and  classified,  but  the  symptom 
common  to  all  of  them  is  the  existence  of  sexual  desires  and  in- 
stincts exactly  opposite  to  those  characteristic  of  the  sex  to  which  the 
patient  belongs.  The  cause  of  this  perversion  is  unknown.  It  is  prob- 
ably associated  with  some  inherited  central  degeneration  in  the  vast 
majority  of  cases,  though  those  in  which  definite  external  influences 


gig  GENITO-URIXARY   DISEASES   AJSTD  SYPHILIS. 

were  observable  have  been  classed  as  "  acquired  homosexuality," 
while  those  in  which  the  perverse  instinct  appeared  spontaneously  at 
or  about  puberty  have  been  called  "  congenital.'" 

"  In  so-called  contrary  sexual  instinct  there  are  degrees  of  the 
phenomenon  which  quite  correspond  ^^ith  the  degrees  of  predisposi- 
tion of  the  individuals.  Thus,  in  the  milder  cases,  there  is  simple 
hermaphroditism ;  in  more  pronounced  cases,  only  homosexual 
feeling  and  instinct,  but  hmited  to  the  vita  sexualis ;  in  still  more 
complete  cases,  the  whole  psychical  personality,  and  even  the  bodily 
sensations,  are  transformed  to  correspond  with  the  sexual  perversion  ; 
and  in  the  complete  cases  the  physical  form  is  correspondingly 
altered."     (Krafft-Ebing.) 

In  accordance  with  this  classification  the  same  author  describes 
the  following  varieties  of  the  disease  : 

1.  Psychical  Hermaphroditism. — The  characteristic  mark  of  this 
degree  of  inversion  of  the  sexual  instinct  is  that,  by  the  side  of  the 
pronounced  sexual  instinct  and  desire  for  the  same  sex,  a  desire 
towards  the  opposite  sex  is  present ;  but  the  latter  is  much  weaker 
and  is  manifested  episodically  only,  while  the  homosexuality  is 
primary,  and  in  time  and  intensity  forms  the  most  striking  feature  of 
the  vita  sexualis. 

It  is  thought  that  such  individuals,  on  account  of  neurasthenia,  of 
masturbation,  or  of  unfavorable  experiences  in  sexual  intercourse 
with  persons  of  the  opposite  sex  (lack  of  pleasure,  weakness  of 
erection,  premature  ejaculation,  infection,  etc),  may  have  the  homo- 
sexual instinct  strengthened,  and  after  satisfying  the  impulse  by 
passive  or  mutual  onanism  with  a  person  of  the  same  sex,  or  by 
coitus  inter  femora,  may  pass  into  the  second  group. 

2.  Urnings. — In  distinction  from  the  preceding  group  of  psycho- 
sexual  hermaphrodites  there  are  here,  ab  origine,  sexual  desires  and 
inclinations  for  persons  of  the  same  sex  exclusively ;  but,  in  contrast 
with  the  following  group,  the  anomaly  is  limited  to  the  vita  sexualis, 
and  does  not  more  deeply  and  seriously  affect  the  character  and 
mental  personality.     (Krafft-Ebing.) 

The  patients  belonging  in  this  class  have  a  disgust  for  coitus  with 
persons  of  the  opposite  sex.  Their  affections  are  apt  to  be  emo- 
tional and  passionate ;  they  present  all  the  phases  of  sentimental 
attachment  to  persons  of  their  own  sex  that  are  seen  in  normal 
individuals  only  between  males  and  females.  They  are  usually 
unable  to  have  intercourse  successfully  in  a  normal  manner,  partly 
because  the  act  of  coitus  is  inhibited  by  their  emotional  condition. 
In  men  of  this  class  mutual  masturbation  and  often  pederasty  afford 


PSYCHOPATHIA   SEXUALIS.  817 

sexual  gratification  ;  in  women,  mutual  masturbation  in  one  form  or 
another. 

3.  Effemination  and  Viraginity. — In  this  class  not  only  the  sexual 
instincts  but  all  the  feehngs  and  inclinations  are  reversed.  The  men 
are  females  in  habits,  sentiments,  and  character;  the  women,  males. 
In  such  cases  heterosexual  love  is  looked  upon  as  incomprehensible, 
and  sexual  intercourse  with  a  person  of  the  opposite  sex  as  impossible. 
In  homosexual  intercourse  the  man  always  feels  himself,  in  the  act, 
as  a  woman ;  the  woman,  as  a  man.  The  means  of  indulgence,  in 
the  case  of  a  man,  where. there  is  irritable  weakness  of  the  ejacu- 
lation centre,  are  simply  succubus,  or  passive  coitus  inter-  femora  ;  in 
other  cases  passive  masturbation,  or  ejaculatio  viri  dilecti  in  ore 
proprio.  Many  have  a  desire  for  passive  pederasty  ;  occasionally  a 
desire  for  active  pederasty  occurs.  The  sexual  satisfaction  of  the 
female  probably  consists  of  amor  lesbicus,  or  active  masturbation. 

4.  Androgyny  and  Gynandry. — In  this  most  extreme  variety  of 
homosexuality  not  only  are  the  character  and  the  feelings  sexually 
reversed,  but  also  the  form,  the  features,  and  the  voice,  so  that  the 
individual  approaches  the  opposite  sex  anthropologically  and  in  more 
than  a  psychical  and  psychosexual  way.  This  anthropological  form 
of  the  cerebral  anomaly  apparently  represents  a  very  high  degree  of 
degeneration  ;  but  that  this  variation  is  entirely  different  from  the 
teratological  manifestation  of  hermaphroditism,  in  an  anatomical 
sense,  is  clearly  shown  by  the  fact  that  thus  far  in  the  domain  of 
contrary  sexuality  no  transitions  to  hermaphroditic  malformation  of 
the  genitals  have  been  observed.  The  genitals  of  these  persons 
always  prove  to  be  fully  differentiated  sexually,  though  not  infre- 
quently there  are  present  anatomical  signs  of  degeneration  (epispa- 
diasis,  etc.),  in  the  sense  of  arrests  of  development  in  organs  that  are 
otherwise  well  differentiated.     (Krafft-Ebing.) 

It  is  impossible  in  this  book  to  pursue  this  interesting  though 
repulsive  subject  further.  The  works  so  freely  quoted  in  the  above 
outline  of  sexual  psychopathy  contain  many  suggestions  as  to  therapy. 
The  most  important  of  these  relate  to  the  prophylaxis  of  such 
troubles  by  early  recognition  of  the  neuropathic  constitution,  the 
prevention  of  onanism,  and  the  encouragement  of  normal  or  hetero- 
sexual impulses  even  in  early  youth  by  regulating  the  sports  and  the 
companions  of  children.  Hypnotic  suggestion  is  being  extensively 
tried  in  adult  cases,  but  no  estimate  of  its  value  can  as  yet  be 
reached. 


CHAPTER   XXII  I. 


SYPHILIS. 


Syphilis  is  a  contagious,  inoculable  disease,  transmissible  by  hered- 
ity. The  first  lesion  of  the  acquired  form  of  syphilis  is  a  chancre ; 
this  is  followed  by  general  lymphatic  enlargement,  by  eruptions  of  the 
skin,  usually  superficial  and  symmetrical  and  associated  with  similar 
lesions  of  the  mucous  membranes  ;  later  by  chronic  inflammation  and 
infiltration  of  the  cellulo-vascular  tissues,  the  bones,  and  the  perios- 
teum, and  finally  by  the  formation  of  small  tumors  called  gummata, 
which  may  appear  in  any  portion  of  the  body,  but  which  commonly 
develop  in  the  connective  tissue. 

Etiology. — Syphilis  is  due  to  the  presence  in  the  system  of  the 
Trepoenema  pallidum  {Spiroehceta  pallida).  There  has  been  adduced 
convincing  proof  of  the  direct  relation  between  the  micro-organisms 
described  and  the  specific  lesions  with  which  they  have  been  found 
associated.  The  clinical  evidence  as  to  the  microbic  nature  of  the 
disease  is  also  conclusive.  The  languor,  pain,  and  fever  preceding  the 
eruption  are  readily  explained  on  the  theory  of  intoxication  by 
ptomaines  engendered  by  the  germs  which  are  not  yet  sufficiently 
generalized  to  produce  more  pronounced  symptoms.  The  eruptions 
on  the  skin  and  mucous  membranes  are  due  to  local  deposits  of  the 
virus  ;  this  is  shown  by  the  fact  that  the  discharges  from  such  lesions 
are  contagious.  The  profound  alteration  in  nutrition  so  often  asso- 
ciated with  the  secondary  eruption  is  due  to  auto-intoxication  by 
tissue-products  passing  into  the  circulation. 

Following  the  secondary  stage  of  the  disease  there  may  be  no 
further  symptoms  of  syphilis,  or,  after  a  period  of  latency,  gummata 
may  develop.  During  this  period  of  latency  or  apparent  cure,  syphilis 
may  be  transmitted  to  offspring,  showing  that  the  active  virus  is  still  in 
the  system.  This  virus  or  its  ptomaines,  however,  absolutely  protect 
against  fresh  inoculation.  A  person  who  has  had  syphilis  is  immune 
against  a  fresh  attack,  positively  during  the  primary  and  secondary 
stages  of  the  disease,  probably  for  many  years  or  for  the  entire  period 
of  life.     It  is  true  that  cases  of  reinfection  are  reported,  but  they  are 

818 


SYPHILIS.  819 

rare ;  the  majority  found  in  medical  literature  are  cases  of  so-called 
relapsing  chancre,  in  reality  a  tertiary  lesion  of  syphilis. 

Immunity  against  Syphilis. — As  a  rule  it  is  found  impossible 
to  inoculate  the  syphilitic  virus  : 

1.  Upon  a  person  who  has  already  suffered  from  the  acquired 
form  of  the  disease. 

2.  Upon  a  person  who  has  inherited  syphilis  from  one  or  both 
parents.     (Profeta's  immunity.) 

3.  Upon  a  mother  who  has  borne  a  syphilitic  child  without  show- 
ing in  her  own  person  any  of  the  lesions  of  acquired  syphilis.  (Colles's 
immunity.) 

The  immunity  against  fresh  infection  conferred  by  acquired  syphi- 
lis is  present  in  the  earliest  stages  of  the  disease,  usually  from  the  first 
appearance  of  the  chancre ;  in  some  cases  even  before  this.  It  per- 
sists long  after  syphilitic  manifestations  have  disappeared,  and  it  can 
be  transmitted  to  offspring  independently  of  the  active  virus. 

These  facts  show  conclusively  that  the  immunity  in  syphilis,  as 
in  other  infectious  diseases,  must  be  due  to  the  tissue-products  of  its 
organized  virus  passing  into  the  circulation. 

Profeta's  immunity — namely,  that  observed  in  the  offspring  of 
syphilitic  parents — is  noted  at  times  in  children  who  exhibit  no  signs 
of  hereditary  syphilis.  Here  inhibiting  tissue-products  without  the 
active  virus  are  present  in  the  circulation.  This  is  also  the  case  in 
Colles's  immunity,  in  accordance  with  which  the  mother  of  a  child 
syphilitic  by  its  father  cannot  be  inoculated  with  syphilis.  The  ex- 
planation of  this  fact  depends  either  on  the  absorption  into  the  mother's 
blood  through  the  placental  circulation  of  only  the  tissue-products  of 
the  specific  micro-organisms,  the  so-called  antitoxins,  or  upon  the  fact 
that  the  mother  is  really  suffering  from  latent  symptoms,  both  the 
active  virus  and  the  tissue-products  having  been  absorbed,  but  having 
been  so  modified  by  pregnancy  that  none  of  the  ordinary  manifestations 
of  the  disease  are  observed. 

Syphilitic  Reinfection.— Although,  as  already  stated,  syphilitic 
reinfection  is  exceedingly  rare,  it  unquestionably  occurs  in  some  few 
cases.  In  the  great  majority  of  those  reported  the  symptoms  could 
be  more  satisfactorily  explained  by  regarding  them  as  the  result  of  a 
recrudescence  of  the  original  attack.  Fournier  states  that  reinfection 
is  certain  only  when  the  following  conditions  can  be  noted  in  their 
proper  chronological  order : 

An  indurated  chancre  with  indolent  inguinal  pleiades  ;  some  weeks 
later,  a  typical  roseola  or  other  syphilitic  eruption,  cephalalgia,  alo- 
pecia, or  mucous  patches ;  a  complete  absence  of  tertiary  accidents 


820  GENITO-UEINAEY   DISEASES  AND   SYPHILIS. 

for  some  years ;  finally  a  new  indurated  chancre  after  a  suspicious 
coitus,  with  characteristic  adenopathies,  followed,  after  some  weeks, 
by  incontestable  secondary  symptoms,  such  as  headache,  alopecia, 
mucous  patches,  typical  eruptions  of  macular  or  papular  syphilo- 
dermata,  or  of  other  syphilides. 

The  difficulty  in  these  cases  lies  in  the  fact  that  it  is  at  times 
impossible  to  distinguish  the  primary  chancre  from  the  indurated 
pseudo-chancre.     The  pseudo-chancres  may  be  divided  into : 

1.  Those  which  develop,  as  the  result  of  the  spontaneous  awaken- 
ing of  the  syphilitic  virus,  at  a  point  where  the  virus  has  already 
manifested  its  action. 

In  this  case  it  is  sometimes  possible,  where  one  has  observed  this 
lesion  at  its  dibut,  to  distinguish  it  from  syphilitic  chancre  ;  for,  accord- 
ing to  the  investigation  of  Fournier,  Vidal,  and  others,  it  begins  by  a 
hardness  profound  from  the  first,  then  becomes  excoriated  and  forms 
a  sore,  while  the  induration  of  the  true  chancre  is  consecutive  to  the 
ulceration,  or,  at  most,  contemporaneous  with  it. 

2.  Those  Avhich  occur  as  the  result  of  an  extrasyphilitic  irritation, 
— the  inoculation  of  the  chancroidal  virus,  for  example,  or  an  outbreak 
of  simple  herpes,  or  the  lesion  of  some  form  of  traumatism.  Here 
the  sore  has  preceded  the  induration. 

Objectively,  these  lesions  may  be  absolutely  identical  with  in- 
durated chancre.  Their  ulceration  is  sometimes  deeper,  but  more 
excavated  and  attended  with  more  secretion ;  these  characteristics 
may,  however,  be  absent. 

There  is  no  authentic  example  of  a  case  of  reinfection  in  a  syphi- 
litic who  is  sufi'ering  from  secondary  manifestations  of  the  disease. 
Reinoculation  practised  upon  persons  presenting  the  tertiary  forms  of 
the  eruption  has  been  uniformly  unsuccessful. 

The  Contagion  of  Syphilis. — The  blood  of  a  syphilitic  during 
the  secondary  period  and  the  secretion  from  a  chancre  or  from  any  of 
the  secondary  lesions  are  contagious.  The  blood  may  carry  contagion 
after  all  the  inflammatory  phenomena  of  Eyphilis  have  disappeared. 

Even  during  the  most  active  stage  of  the  disease  the  normal  secre- 
tions, the  saliva,  the  sweat,  the  milk,  and  the  semen,  will  not  convey 
the  disease,  provided  they  have  not  mixed  with  them  a  dischai^e 
from  some  of  the  inflammatory  lesions.  It  is  possible  that  in  the 
passage  of  the  serum  of  the  blood  through  the  glandular  membranes 
and  cells  the  contagious  particles  are  strained  out. 

Although  the  semen  cannot  convey  contagion,  it  must  contain  the 
virus  in  some  form,  since  it  is  able  to  infect  the  embryo,  and,  by  this 
means,  the  organism  of  the  mother. 


SYPHILIS.  821 

After  the  primary  and  secondary  stages  of  the  disease,  both  the 
blood  and  the  discharge  from  the  lesions  are  innocuous,  so  far  as  the 
conveyance  of  syphilis  is  concerned.  This  condition  is  generally 
reached  at  the  end  of  two  years.  After  three  years  contagion  is 
almost  unknown,  and,  according  to  Hutchinson,  there  is  no  recorded 
instance  of  its  having  taken  place  after  five  years.  Nevertheless,  inflam- 
matory lesions  the  result  of  syphilitic  poison  may  appear  for  many  years 
after  the  virus  has  lost  its  power  of  contagion.  Moreover,  inoculation 
with  the  scrapings  of  unbroken  gummata  will  cause  the  development 
of  chancre  in  the  orang-outang  in  more  than  half  the  experiments. 

Whether  contagion  be  derived  from  the  discharge  of  a  chancre, 
from  that  of  a  mucous  patch,  or  from  the  blood  of  a  syphilitic,  the 
primary  lesion  at  the  seat  of  inoculation  is  invariably  a  chancre. 

Except  in  the  hereditary  and  conceptional  forms,  a  chancre  is 
always  the  starting-point  of  syphilis.  Filtering,  heating  for  an  hour 
to  51°  C,  or  desiccation,  renders  the  virus  non-inoculable. 

Methods  of  Contagion. — Syphilis  has  been  aptly  compared  by 
Hutchinson  to  the  contagious  eruptive  fevers,  such  as  small-pox  and 
scarlet  fever.  Like  these  fevers,  it  is  communicated  from  a  diseased 
person  to  a  healthy  one,  and  the  smallest  portion  of  virus  can  affect 
the  whole  body.  It  has  its  stages  of  incubation,  eruption,  and  dechne, 
and  also  its  sequelae,  the  latter  not  always  appearing,  and  usually  being 
non-contagious ;  it  can  be  transmitted  to  offspring,  b^it  its  sequelae 
cannot  be  so  transmitted. 

It  differs  from  the  other  exanthemata  in  the  slowness  of  its  course, 
in  the  comparative  mildness  of  its  constitutional  symptoms,  and  in 
requiring  actual  contact  before  it  can  be  transmitted.  The  method  of 
infection  is  by  inoculation  or  heredity. 

The  contagion  may  be  either  immediate  or  mediate. 

Immediate  contagion — that  is,  contagion  direct  from  one  individual 
to  another — usually  takes  place  during  sexual  approach,  though  it 
may  occur  from  unnatural  practices,  from  kissing,  from  wounds  in- 
flicted by  the  teeth  of  syphilitics,  or,  in  the  case  of  medical  men,  from 
operating  on  syphilitic  patients,  when  the  hands  of  the  operator  are 
wounded  or  abraded. 

Inoculation  is  more  readily  accomplished  through  a  superficial  abra- 
sion than  through  a  distinct  wound. 

Mediaie  Contagion. — In  this  form  of  contagion  the  disease  is  con- 
veyed not  by  direct  surface  contact,  but  by  means  of  spoons,  glasses, 
pipes,  clothing,  etc.,  upon  which  the  specific  virus  is  deposited  by  a 
person  suffering  from  some  of  the  lesions  of  syphilis,  and  from  which 
it  is  inoculated  in  some  surface  break  of  a  person  not  immune  to  the 


822  GENITO-URINARY   DISEASES    AND   SYPHILIS. 

disease.  The  list  of  articles  which  have  thus  conveyed  syphilis  is 
comprehensive.  Among  the  frequent  carriers  of  contagion  are  pipes, 
cigars,  razors,  surgical  and  dental  instruments,  handkerchiefs  and 
articles  of  clothing,  and  human  vaccination  lymph.  Many  unusual 
methods  of  contagion  have  been  observed. 

In  one  case  of  Hunterian  chancre  of  the  arm  the  contagion  was 
conveyed  through  a  slight  scratch  by  means  of  a  towel.  Melot  reports 
a  nasal  chancre  developing  in  a  pedestrian  who  was  accidentally  hit  by 
the  whip-lash  of  a  passing  teamster.  The  latter,  who  was  syphilitic, 
had  formed  the  habit  of  biling  his  lash. 

Types  of  Syphilis. — Sypliilis  may  begin  and  end  with  chancre 
and  inguinal  adenitis,  no  other  symptoms  developing.  Under  these 
circumstances  doubt  may  reasonably  be  entertained  as  to  the  nature 
of  the  original  sore.  It  has,  however,  been  proved  beyond  contra- 
diction that  after  such  a  sore  and  the  entire  absence  of  secondaries 
unmistakable  tertiary  lesions  may  appear  years  later,  and  it  seems 
reasonable  to  conclude  that  infection  may  exceptionally  be  so  mild 
that  it  is  sufficiently  overcome  by  systemic  resistance  in  its  primary 
stage  to  prevent  the  secondary  efflorescence. 

The  disease  may  have  for  its  manifestations  a  chancre,  general 
adenitis,  and  one  light  outbreak  of  macular  or  papular  eruption 
involving  the  skin  and  the  mucous  surfaces  of  the  mouth  and  throat, 
thereafter  showing  no  signs. 

More  commonly  following  the  chancre  there  is  a  single  exan- 
thematous  outbreak,  disappearing  promptly  under  treatment,  but  re- 
curring occasionally,  particularly  in  the  mouth  and  throat.  These 
recurrences  yield  promptly  to  more  vigorous  antisyphihtic  treatment, 
and  are  not  followed  by  tertiaries.  The  types  of  disease  thus  de- 
scribed are  termed  benign,  but  any  of  them  may  be  followed  by 
tertiary  manifestations  of  the  most  dangerous  and  incurable  form. 

Exceptionally  the  disease  is  distinctly  atypical  in  its  development, 
deep  ulcerating  and  infiltrating  lesions  appearing  in  the  early  second- 
ary period.     In  these  cases  syphilis  may  assume  a  malignant  type. 

This  form  of  the  disease  is  characterized  by  its  acute  course. 
Even  the  chancre  exhibits  a  destructive  tendency,  resembling  in  its 
development  phagedenic  chancroid.  Syphilitic  fever,  concomitant 
rheumatism,  and  anaemia  are  well  marked.  The  first  eruption  quickly 
becomes  pustular,  and  ulcers  form  which  are  deep  enough  to  leave 
pigmented  scars  on  the  skin,  and  in  the  mouth  and  nose  to  involve 
the  superficial  bones  and  cartilages,  causing  necrosis  and  deformity. 
Deep  ulcers  and  ulcerating  gummata  appearing  in  the  secondary 
period  are  especially  characteristic  of  this  form  of  syphilis.     Recur- 


SYPHILIS.^ 


823 


rences  following  hard  upon  one  another  are  also  typical  of  malignant 
syphilis,  while  early  involvement  of  the  bones,  the  nervous  system, 
and  the  viscera  is  not  uncommon.  In  the  latter  case  syphilitic 
marasmus  and  death  often  result. 

The  malignant  form  of  the  disease  seems  to  depend  not  so  much 
upon  the  virulence  of  the  infection  as  upon  the  lessened  tissue  resist- 
ance. Thus,  syphilis  is  prone  to  exhibit  its  malignant  form  in  the 
weak,  the  anaemic,  chronic  drunkards,  the  scrofulous,  the  tuberculous, 
the  malarial,  and  in  pregnant  or  nursing  women. 

Periods  of  Syphilis. — In  accordance  with  its  clinical  course  the 
phenomena  of  acquired  syphilis  are  classed  under  certain  periods. 
These  are  as  follows : 

1.  The  Period  of  Primary  Incubation. — The  time  intervening  be- 
tween exposure  to  contagion  and  the  appearance  of  the  chancre.  This 
is,  on  an  average,  three  weeks. 

2.  The  Period  of  Primary  Symptoms. — The  chancre  develops  and 
the  anatomically  related  glands  become  enlarged.  This  period,  on  an 
average,  is  from  three  to  ten  days. 

3.  The  Period  of  Secondary  Incubation. — The  time  elapsing  be- 
tween the  appearance  of  the  chancre  and  the  development  of  secondary 
symptoms.  This  is,  on  an  average,  about  six  weeks,  and  includes,  of 
course,  the  period  of  primary  symptoms. 

4.  The  Period  of  Secondary  Symptoms. — Syphilitic  fever,  anaemia, 
neuralgic  pains,  and  the  syphilides  of  the  skin  and  mucous  mem- 
branes develop  during  this  period.  This  is,  on  an  average,  from 
twelve  to  eighteen  months. 

5.  Intermediate  Period. — During  this  time  the  patient  may  be  en- 
tirely free  from  any  signs  of  syphilis,  or  he  may  suffer  from  slighter, 
more  irregular,  less  symmetrical,  and  less  generalized  symptoms  than 
those  of  the  secondary  stage.  Children  begotten  by  a  patient  in  the 
first  half  of  this  stage  of  the  disease  often  show  the  signs  of  hereditary 
syphilis.  This  period  lasts  from  two  to  four  years.  It  may  terminate 
in  complete  recovery  or  may  be  followed  by : 

6.  The  Period  of  Tertiary  Symptoms. — This  is  characterized  either 
by  the  formation  of  gummata  or  by  diffuse  infiltration  of  various 
organs.  Chronic  periostitis  and  ostitis,  skin  diseases  of  the  tuberculo- 
ulcerous  type,  disease  of  the  nervous  system,  etc.,  are  encountered 
during  this  stage.  In  the  majority  of  properly  treated  cases  the 
lesions  of  this  period  never  appear;  though  they  may  develop  at 
any  time  subsequent  to  the  chancre,  they  commonly  are  seen  in  the 
third  and  fourth  years  following  the  primary  lesion. 

It  must  be  understood  that  this  division  of  syphilis  into  periods  is 


824 


GENITO-UEINAKY  DISEASES  AND   SYPHILIS. 


to  an  extent  artificial,  there  being  rarely  any  sharp  limitations ;  one 
period  runs  insensibly  into  another.  Indeed,  it  is  possible  that  lesions 
of  primary,  secondary,  and  tertiary  syphilis  may  all  be  present  at  the 
same  time. 

The  Period  of  Primary  Incubation. — In  a  person  exposed 
to  contagion  the  lesion  of  syphilis  does  not  develop  immediately. 
Although  there  is  little  reason  to  suppose  that  the  virus  of  syphiHs 
remains  localized  during  the  entire  period  elapsing  between  inoculation 
and  the  appearance  of  the  chancre,  it  is  probable  that  it  remains  at 
or  near  the  seat  of  inoculation  a  certain  length  of  time,  and  hence  if 
immediately  removed  by  caustic  applications  or  by  surgical  operation^ 
local  and  general  symptoms  of  syphihs  will  not  follow.  There  are 
cases  on  record,  however,  which  seem  to  disprove  this.  Abrasions 
through  which  the  virus  might  have  been  absorbed  have  been  cut 
out  a  few  hours  after  suspicious  connection,  and  yet  characteristic 
induration  and  secondary  symptoms  of  syphilis  have  developed  at  the 
regular  time.  It  is,  of  course,  possible  that  excision  in  these  cases 
was  not  sufficiently  thorough.  Such  instances  show  that  even  after 
very  early  removal  the  prognosis  concerning  subsequent  disease  must 
be  exceedingly  guarded. 

It  is  possible  that  syphilis  may  be  acquired  from  contact  with  the 
virus  through  unbroken  surfaces,  especially  where  the  epidermis  is- 
extremely  thin ;  but  the  presence  of  fissures  or  of  abrasions  greatly 
facilitates  the  contraction  of  the  disease. 

As  has  been  said,  from  whatever  source  the  contagion  is  derived,. 
a  chancre  at  the  point  of  inoculation  is  the  invariable  result. 

The  period  of  primary  incubation  varies  from  ten  days  to  three 
months.  The  average  period  is  three  weeks.  As  a  rule,  it  is  safe  to 
assume  that  any  sore  which  appears  more  than  ten  days  after  the  last 
exposure  to  contagion  is  a  chancre.  During  the  period  of  primary- 
incubation  there  are  neither  general  nor  local  symptoms. 

THE  PERIOD   OF   PRIMARY  LESION. 

After  the  period  of  primary  incubation  the  primary  lesion  of 
syphihs,  a  chancre,  develops.  This  begins  as  a  spot  of  erythema, 
which  in  a  few  hours  becomes  a  superficial  papule;  it  gradually 
extends  in  circumference  and  depth,  loses  its  epithehal  or  epidermic 
covering,  and  in  the  course  of  a  few  days  is  surrounded  by  an  area 
of  induration.  This  represents  the  development  of  a  typical  chancre. 
Frequently,  however,  the  chancre  when  first  seen  appears  as  a  fissure 
or  an  abrasion,  or,  if  located  on  the  mucous  membrane,  as  a  super- 
ficial  ulceration  covered  by  a  grayish  or  yellowish  false  membrane. 


A' 


\ 


SYPHILIS.  825 

Oflen  there  is  no  break  in  the  continuity  of  the  epidermis  overlying 
a  chancre,  but  merely  a  gradual  thinning  of  this  layer  of  the  skin  from 
the  margins  towards  the  centre. 

When  actual  ulceration  exists  it  forms  a  simple  cup-shaped  depres- 
sion, with  sloping  margins  and  smooth  surface,  in  the  centre  of  which 
is  a  false  membrane  ;  beneath  this  there  is  a  granulating  surface,  which 
bleeds  readily  on  mechanical  interference. 

As  synonymes  for  chancre  the  following  terms  are  employed : 
Hunterian  chancre;  infecting  chancre;  hard  chancre;  indurated  neo- 
plasm ;  primary  sore. 

The  chancre  is  usually  single.  When  the  virus  has  been  inocu- 
lated at  the  same  time  in  several  places  a  number  of  sores  may  appear, 
but  they  all  develop  at  the  same  time,  and  are  never  due  to  inocula- 
tion of  surrounding  or  apposing  surfaces  with  the  discharge  of  a  first 
sore.    Multiple  chancres  occur  in  eighteen  per  cent.  (Fournier)  of  cases. 

Induration. — In  from  five  to  ten  days  the  most  characteristic 
feature  of  chancre,  the  induration,  becomes  perceptible  ;  it  commonly 
reaches  its  maximum  in  about  two  weeks  from  the  appearance  of 
the  chancre.  In  some  cases  the  induration  is  entirely  absent.  It  is 
present  and  distinct  in  the  great  majority  of  cases,  but  may  appear  in 
different  forms.  This  hardening  about  the  primary  lesion  of  syphilis 
is  due  to  a  cellular  infiltration  of  the  connective  tissue  and  of  the  coats 
of  the  venules  and  arterioles,  affecting  chiefly  the  tunica  adventitia  of 
the  latter.  It  is  the  thickening  of  the  blood-vessel  Avails  which,  in 
conjunction  with  the  cellular  infiltration,  gives  to  the  chancre  the 
specific  induration. 

The  blood-vessels  of  the  skin  form  two  horizontal  net-works, — one 
beneath  the  papillae,  the  other  in  the  deepest  portion  of  the  derm. 
When  only  the  superficial  net-work  of  vessels  is  sclerosed  there  is 
simply  a  surface  induration ;  when  both  net-works,  together  with  the 
intermediate  branches,  are  affected,  there  is  a  distinct  nodule,  varying 
in  thickness  according  to  the  extent  of  skin  surface  involved.  Nearly 
always  the  vascular  sclerosis  is  continued  far  beyond  the  area  of  indu- 
ration, but  usually  in  such  a  comparatively  slight  degree  that  the  line 
of  demarcation  between  the  borders  of  the  chancre  and  the  sur- 
rounding tissue  is  distinctly  marked. 

In  accordance  with  its  depth  the  induration  is  classified  as  follows : 

1.  Laminated  Induration. — The    hardening    around    the    lesion, 

though  distinctly  outlined  from  the  surrounding  tissues,  forms  a  layer 

so  thin  that  it  gives  to  the  examining  fingers  a  sensation  as  if  a  disk  of 

writing-paper  had  been  inserted  in  the  superficial  layers  of  the  skin. 

2.  Parchment  Induration. — This  is  somewhat  thicker  than  the  lam- 


826  GENITO-UKINAEY  DISEASES  AND   SYPHILIS. 

inated  induration,  giving  on  palpation  such  a  sensation  as  would  be 
conveyed  v^ere  the  lesion  placed  upon  a  disk  of  parchment. 

3.  Nodular  Induration. — This,  in  the  absence  of  acute  inflamma- 
tion, is  the  most  characteristic  form  of  induration.  It  is  hard  and 
thick,  feeling  like  a  nodule  of  v^ood  or  of  cartilage.  •  In  well-developed 
cases  of  this  nature  not  only  the  vessels  of  the  skin  but  also  those  of 
the  subdermic  connective  tissue  are  involved.  The  hardening  is  in 
some  cases  so  great  as  to  suggest  the  presence  of  malignant  growth. 

4.  Annular  Induration. — As  is  implied  by  the  name,  this  form  of 
induration  affects  only  the  margins  of  the  chancre,  a  hard  ring  being 
formed  about  the  centre,  which  retains  almost  normal  elasticity. 

The  induration  of  the  chancre  is  best  detected  by  gently  pinching 
together  the  soft  parts  wide  of  the  lesion  till  the  hardened  edges  are 
felt  by  the  thumb  and  fmger  placed  on  opposite  sides  of  the  sore  ;  the 
whole  plaque  is  then  lifted  upward  from  the  subcutaneous  tissues, 
when,  by  further  gentle  pressure  and  palpation,  the  depth  and  extent 
of  the  induration  can  be  readily  determined. 

As  would  be  supposed  from  a  knowledge  of  the  cause  of  indu- 
ration, the  extent  of  the  latter  varies  in  accordance  with  the  seat  of 
the  primary  lesion.  When  occurring  upon  the  glans  penis,  upon 
the  mucous  membrane  of  the  prepuce,  or  in  the  fossa  glandis,  the 
chancre  is  usually  very  distinctly  indurated.  Upon  the  skin  of  the 
penis  and  the  general  integument  induration  is  not  so  marked.  In 
women  the  induration  of  the  primary  lesion  is  far  less  distinct  than 
is  the  case  with  men ;  when  the  chancre  is  situated  upon  the  labia 
majora  the  characteristic  hardening  is  more  pronounced  than  when 
it  involves  the  labia  minora  or  the  fourchette. 

The  chancre,  if  ulcerated,  commonly  heals  in  four  to  six  weeks, 
the  induration  lasting  not  much  longer  than  this,  though,  if  it  has 
been  distinctly  nodular  in  character,  it  may  persist  for  months  and 
even  years,  or,  after  having  entirely  disappeared,  may  again  become 
marked,  constituting  a  form  of  the  so-called  pseudo-chancre. 

Location  of  the  Chancre. — The  chancre  may  be  located  on  any 
part  of  the  body.  Genital  chancres  are  those  placed  on  or  about  the 
genitalia.  The  great  majority  of  chancres,  especially  in  men,  are 
genital  or  perigenital. 

Extragenital  chancres  are  those  situated  on  other  surfaces  of  the 
body.  The  disease  when  acquired  in  ways  other  than  by  normal  or 
perverted  sexual  congress  is  termed  syphilis  insontium.  The  extra- 
genital chancre  may  be  found  on  any  portion  of  the  surface  of  the 
body  exposed  to  contact  with  syphilitic  virus.  The  usual  seats  of 
such  chancres  are  the  lips,  the  mucous  surfaces  of  the  mouth  and 


Fig.  255. 


Chancre  of  the  reflected  layer. 


Fig.  256. 


Chancre  of  the  meatus. 


Fig.  257. 


Chancre  of  the  coronary  sulcus. 


SYPHILIS.  327 

pharynx,  the  region  of  the  anus,  and  the  region  of  the  nipple.  In 
the  mouth  the  chancre  is  commonly  found  on  the  tongue,  excep- 
tionally on  the  tonsils  or  the  half-arches.  Among  surgeons  and 
accoucheurs  extragenital  chancre  is  usually  found  on  the  fingers  or 
hand.  With  very  few  exceptions,  extragenital  chancres  are  acquired 
in  innocent  ways ;  even  the  anal  chancres  often  noted  in  women  are 
commonly  due  to  infection  by  discharges  flowing  backward  from  the 
vagina.  Extragenital  chancres  rarely  present  the  typical  features  of 
the  sore  as  observed  about  the  genitaha.  At  times  the  lesions  are 
so  slight  as  to  excite  scarcely  any  attention ;  more  commonly  inflam- 
matory symptoms  become  so  pronounced  that  characteristic  indu- 
ration, if  present,  is  entirely  masked,  and,  except  in  the  clinical  history 
of  the  case,  there  is  nothing  to  suggest  that  the  sore  is  syphilitic  in 
nature.  Chancres  of  the  face  and  lips  are  often  much  larger  than  the 
average  genital  chancre,  and  sometimes  form  huge  ulcers. 

THE   GENITAL    CHANCRE. 

The  common  position  of  the  genital  chancre  in  men  is  on  the  mucous 
membrane  of  the  prepuce  in  or  just  behind  the  coronary  sulcus  (Figs. 
255-257),  on  the  surface  of  the  glans  penis,  particularly  in  the  region 
of  the  frsenum,  and  about  the  margin  of  the  preputial  opening.  Three- 
fourths  of  all  chancres  are  in  these  localities.  The  primary  sore  is 
found  at  times  at  the  meatus  urinarius,  on  the  skin  of  the  penis,  on 
the  groin  or  the  scrotum,  and  in  the  urethra.  The  characteristic  indura- 
tion is  most  marked  in  those  chancres  found  at  the  seats  of  prefer- 
ence— i.6.,  on  the  mucous  membrane  of  the  prepuce  just  behind  the 
sulcus.  Upon  the  surface  of  the  glans,  in  the  region  of  the  frtenum, 
and  about  the  urinary  meatus  the  induration  is  often  slight,  and  the 
sore  frequently  assumes  a  distinctly  inflammatory  type.     (Fig.  256.) 

On  the  free  edge  of  the  prepuce  the  induration  may  be  absent  or 
may  form  a  ring  of  great  hardness. 

In  women  chancres  are  commonly  placed  on  the  labia  majora  or 
labia  minora.  They  are  not  infrequently  found  in  the  regions  of  the 
fourchette  and  the  clitoris,  and  have  occasionally  been  observed  about 
"he  OS  uteri.  They  are  rare  upon  the  surface  of  the  vagina,  although 
this  canal  is  probably  more  exposed  to  contagion  than  any  other  sur- 
face. This  immunity  is  due  to  the  structure  of  the  vaginal  mucous 
membrane,  which,  being  guarded  with  thick  layers  of  flat  epithelial 
cells,  and  having  no  glandular  orifices,  forms  an  efficient  barrier 
against  microbic  infection.  The  inguinal  glands  are  primarily  involved 
only  when  the  lesion  is  placed  in  the  anterior  third  of  the  canal. 

As  has  been  said,  the  induration  of  chancre  is  far  less  marked  in 
women  than  in  men ;  the  typical  sharply  circumscribed  cartilaginous 


828  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

hardening  is  rarely  observed ;  it  is  replaced  by  a  more  diffuse  and 
less  sharply  marked  infiltration,  often  very  little  greater  than  would 
attend  a  non-specific  lesion  of  the  same  size. 

Varieties  of  the  Genital  Chancre. — Although  the  primary 
lesion  may  appear  in  a  great  variety  of  forms,  the  majority  of  cases 
present  certain  characteristic  features,  enabling  them  to  be  considered 
under  a  few^  headings. 

In  the  order  of  their  relative  frequency  chancres  may  be  classed  as : 

1.  Chancrous  erosions. 

2.  Chancrous  ulcerations. 

3.  Indurated  papules. 

Exceptionally  there  are  observed  certain  erratic  forms  of  chancre 
which  would  not  strictly  fall  under  any  of  these  headings.  Among 
these  are  encountered : 

1.  The  multiple  herpetiform  chancre,  closely  resembling  herpes, 
but  not  presenting  the  multiple  circinate  margin  of  the  latter,  not 
giving  the  characteristic  exudation  of  herpes  on  pressure,  and  having 
a  different  clinical  history. 

2.  The  "  silvery  spot,"  a  lesion  such  as  would  be  produced  by  the 
application  of  a  finely  pointed  silver  nitrate  stick,  generally  situated 
on  the  surface  of  the  glans  penis,  and  often  giving  place  finally  to  the 
chancrous  erosion. 

3.  The  mixed  chancre,  a  lesion  which  results  from  the  action  of 
both  the  chancroidal  and  the  syphilitic  virus.  The  chancroid  runs  its 
typical  course  and  may  be  healed  before  the  syphilitic  induration  is 
noted.  More  frequently  there  is  a  persistent  chancroidal  ulceration, 
around  which  the  hardening  of  the  true  chancre  appears  at  its  regular 
time. 

1.  The  Chancrous  Erosion. — ^About  two-thirds  of  all  genital 
chancres  appear  in  the  form  of  chancrous  erosions.  The  lesion  at 
first  looks  like  a  small  abrasion,  such  as  might  result  from  a  very 
slight  scratch  with  the  finger-nail.  As  the  chancre  develops  it  be- 
comes oval  or  round  in  shape,  is  surrounded  by  a  dusky-red  areola, 
presents  a  polished  raw  surface,  the  central  portion  of  which  is 
covered  by  a  gray  false  membrane,  and  discharges  a  small  quantity 
of  blood-stained  serum.  The  lesion  is  an  exfoliation  of  the  epi- 
derm,  exposing  but  not  destroying  the  true  skin.  The  induration 
develops  in  about  a  week  from  the  beginning  of  the  erosion,  and  is 
usually  parchment-like,  though  it  may  be  nodular. 

2.  The  Chancrous  Ulceration. — This  form  of  chancre  exhibits  a 
deeper  ulceration  than  the  chancrous  erosion.  The  latter  causes 
epithelial  desquamation ;  the  former  involves  the  true  skin,  or,  in  its 


Fig.  258. 


Chancre  of  the  corona.    (Fox.) 


SYPHILIS.  829 

more  exaggerated  form,  the  subcutaneous  tissues.  The  chancrous 
ulceration  may  be  superficial  or  deep. 

The  superficial  form  of  chancrous  ulceration,  called  by  Fournier 
the  exulcerative  chancre,  attacks  the  true  skin,  but  does  not  entirely 
destroy  it.  An  ulcer  is  formed  of  moderate  depth,  with  sloping  edges 
and  a  scanty  sero-sanguineous  discharge.  The  granulating  surface 
is  frequently  covered  by  a  gray  adherent  false  membrane.  The  indu- 
ration is  more  marked  than  in  the  chancrous  erosion,  being  rather 
of  the  nodular  than  of  the  parchment  variety.     (Fig.  258.) 

The  deep  form  of  chancrous  ulceration,  called  by  Fournier  the 
ulcerative  chancre,  is  comparatively  rare.  There  is  formed  a  deep 
ulcer  with  sloping  edges,  moderate  sero-sanguineous  discharge,  and 
typical  extensive  cartilaginous  induration  into  which  the  ulcer  seems 
to  have  eaten. 

3.  The  Indurated  Papule. — This  primary  lesion  of  syphilis  differs 
from  the  chancrous  erosion  in  the  fact  that  the  skin  is  not  broken.  A 
hard,  raised,  dusky-red  tubercle  is  formed,  sharply  defined  from  the 
surrounding  tissues.  The  surface  is  dry,  but  is  frequently  crusted 
with  layers  of  exfoliated  epithelium.  The  papule  may  be  large  and 
prominent,  or  so  small  as  to  escape  the  notice  of  the  patient. 

Complications  of  Chancre. — The  types  of  genital  chancre  just 
described  may  be  so  modified  that  they  present  an  appearance  en- 
tirely different  from  that  commonly  supposed  to  be  characteristic  of 
the  primary  lesion  of  syphilis. 

The  modification  may  be  brought  about  by:  1.  simple  inflam- 
mation ;  2,  chancroidal  inflammation  ;  3,  papillary  growth  ;  4,  con- 
version into  a  mucous  patch  ;  5,  phagedsena  and  gangrene. 

Simple  inflammation  may  attack  a  chancre  as  a  result  of  inocula- 
tion with  the  ordinary  micro-organisms  of  suppuration.  This  will  be 
more  likely  to  take  place  if  the  chancre  is  exposed  to  irritating  appli- 
cations, to  friction,  or  to  any  mechanical  injury  which  will  render  the 
soil  favorable  to  the  multiplication  of  pyogenic  microbes.  The  chancre 
will  be  modified  by  the  local  signs  of  acute  inflammation,— namely, 
heat,  pain,  redness,  swelling,  and  free  discharge.  As  a  further  com- 
plication, suppurating  buboes  may  form  in  the  groins. 

Chancroidal  Inflammation. — The  virus  of  chancroid  and  that  of 
syphilis  may  be  inoculated  at  the  same  time.  In  this  case  the  chancroid 
will  appear  first,  and  may  even  have  run  its  course  and  be  completely 
cicatrized  before  the  characteristic  induration  of  the  chancre  is  noted. 
More  commonly  the  chancroid  persists,  the  spreading,  inflamed, -slough- 
ing, punched-out,  freely  discharging  ulcer  becoming  gradually  envel- 
oped in  a  hardened  infiltrate  as  the  period  for  the  full  local  develop- 
ment of  the  syphilitic  lesion  is  reached.     In  place  of  being  acquired 


830  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

at  the  same  time,  the  chancroidal  virus  may  be  inoculated  on  a 
well-developed  chancre ;  the  result  of  this  will  be  the  formation  of  a 
chancroid,  the  induration  being  the  only  remaining  local  symptom 
to  suggest  chancre.  If  the  chancroid  spread  rapidly  it  may  cause 
sloughing  of  the  indurated  area,  in  that  case  leaving  no  local  sign 
which  would  suggest  syphihs ;  or  the  syphilitic  virus  may  be  inocu- 
lated on  the  chancroid,  the  latter  then  running  its  course  unaltered 
except  for  the  formation  of  an  induration. 

A  sore  resulting  from  the  inoculation  of  both  syphilis  and  chan- 
croid at  the  same  spot  is  called  a  mixed  chancre.  It  is  liable  to  any 
of  the  complications  which  follow  the  inoculation  of  either  of  the 
poisons  separately. 

Papillary  Outgrowth  and  Conversion  of  the  Chancre  into  a  Mucous 
Patch  or  Condyloma. — Associated  with  the  chancre  there  is  often  an 
abundant  outgrowth  of  warts,  such  as  are  common  in  balanoposthitis 
or  other  inflammatory  conditions  of  the  glans  and  the  prepuce.  These 
warts  seem  to  be  due  simply  to  irritation,  and  are  not  specific  in  theii 
nature.  The  chancre  itself  at  times  loses  its  induration  as  secondary 
symptoms  develop,  becomes  covered  with  gray  false  membrane,  and 
presents  all  the  characteristics  of  a  mucous  patch  ;  or  the  papillary 
layer  of  the  skin  may  proliferate,  forming  a  condyloma,  a  broad,  flat 
elevation,  the  surface  of  which  is  covered  with  a  gray,  adherent 
pellicle. 

Phagedcena  and  Gangrene. — Phagedsena  may  be  regarded  as  the 
result  of  inflammation  more  rapid  and  intense  than  that  which  char- 
acterizes the  inflamed  chancre.  The  engorgement  becomes  so  great 
that  there  is  loss  of  vitahty,  and  sloughs  are  formed,  or  gangrene  may 
attack  the  tissues.  More  rarely  it  progresses  slowly,  the  ulcerating 
process  being  then  termed  serpiginous. 

Phagedsena  is  more  liable  to  occur  in  persons  of  depressed  consti- 
tution, yet  it  is  noted  at  times  in  the  robust.  There  is  undoubtedly 
a  systemic  predisposition,  which  is  in  many  cases  successfully  com- 
bated by  specific  treatment;  the  exciting  cause  is,  however,  purely 
local ;  this  is  shown  by  the  fact  that  in  the  same  person  one  sore 
may  become  phagedenic  while  another  pursues  an  uncomplicated 
course. 

Phagedsena  may  attack  the  chancre  at  any  stage  of  its  develop- 
ment, or  may  complicate  any  of  the  secondary  or  tertiary  ulcerations 
of  the  disease.  If  rapid,  it  destroys  the  induration  more  c|uickly  than 
it  can  form,  and  thus  removes  the  most  characteristic  feature  of  the 
chancre. 

Diagnosis  of  Ohancre. — Under  ordinary  circumstances  the  clin- 
ical diagnosis'  of  chancre  is  comparatively  easy,  yet  it  must  be  remem- 


SYPHILIS.'  .  831 

bered  that  there  is  no  infalUble  sign,  and  that  the  primary  lesion  of 
syphilis  may  present  only  the  features  of  a  simple  ulcer.  It  is  safe  to 
refuse  to  give  a  positive  opinion  from  the  examination  of  the  sore  alone. 

The  absolute  diagnosis  of  chancre  is  made  by  finding  the  Trypo- 
nemata.  These  appear  as  fine,  closely  coiled  spirals  6  to  15  microns 
long,  feebly  motile.  Most  abundant  in  the  margin  of  the  lesions  and 
usually  beneath  the  surface.  They  are  practically  constant  in  chancre 
and  mucous  patches,  and  are  frequently  found  in  syphilitic  buboes. 
Old  chancres  and  those  treated  by  local  antiseptics  may  easily  fail  to 
show  the  organisms. 

The  area  of  the  sore  to  be  examined  is  gently  scraped  and  the 
scrapings  wiped  away ;  then  sufficient  serum  is  pressed  out  to  be 
removed  by  a  platinum  loop.  This  is  mixed  with  a  drop  of  distilled 
water  and  placed  upon  a  slide  upon  which  a  cover  glass  is  pressed  down 
firmly.  The  moving  organism  can  be  detected  at  once  by  means  of  a 
parabloid  condenser,  all  the  rays  of  light  being  so  converged  that  there 
is  a  dark  background  formed  in  which  the  Tryponema  appears  as  a 
bright  body.     Negative  results  are  conclusive  only  after  repeated  trials. 

In  the  absence  of  microscopic  examination,  an  opinion  as  to  the 
nature  of  a  genital  sore  will  be  formed  after  due  consideration  of  the 
following  points : 

1.  Confrontotion,  or  examination  of  the  person  from  whom  the 
lesion  was  presumably  acquired.  Even  though  he  or  she  is  found 
to  be  suffering  from  symptoms  of  primary  or  secondary  syphilis,  it  is 
not  proper  to  conclude  that  the  lesions  acquired  are  necessarily 
specific.  They  may  be  of  mechanical,  herpetic,  or  chancroidal  origin. 
This  method  of  diagnosis  is  rarely  practicable  in  this  country. 

2.  The  History  of  Incubation. — A  lesion  developing  in  less  than 
five  days  from  exposure  is  certainly  not  specific.  One  developing 
in  from  ten  days  to  five  weeks  is  probably  specific,  unless  some  other 
cause,  such  as  mechanical  or  chemical  irritation,  or  fresh  exposure, 
can  be  assigned  for  it. 

3.  The  Development  of  the  Lesion. — When  this  begins  as  a  macule, 
or  slight  painless  excoriation,  or  scratch,  which  persists  in  spite  of 
careful  local  treatment,  which  slowly  spreads  without  marked  inflam- 
matory symptoms,  which  becomes  distinctly  hard  peripherally  and  at 
the  base  as  though  there  were  a  dense  cellular  infiltrate,  and  which 
gives  a  thin,  scanty  discharge,  showing  a  tendency  to  crust  or  to  form 
a  pseudo-membranous  deposit  covering  the  excoriated  surface,  the 
diagnosis  of  chancre  can  be  made  with  considerable  confidence. 

4.  Induration. — When  the  lesion,  be  it  papule,  erosion,  or  ulcer, 
develops  the  laminated,  parchment,  or  nodular  induration,  a  sharply 


832  GENITO-UEINAEY   DISEASES    AND   SYPHILIS. 

circumscribed  hardening,  spreading  wide  of  the  central  lesion  and 
absolutely  unlike  the  general  thickening  about  an  area  of  simple 
inflammation,  it  is  almost  certainly  a  chancre. 

5.  Lymphatic  Involvement. — If  the  lymphatic  glands  of  the  groin 
steadily  increase  in  size  and  hardness,  without  accompanying  pain  or 
other  symptom  of  acute  inflammation,  forming  a  chain  of  little  tumors, 
including  several  or  all  of  the  inguinal  glands  of  both  sides,  the  evi- 
dence as  to  the  specific  nature  of  a  genital  lesion  is  still  further 
strengthened. 

The  chief  considerations  on  which  a  diagnosis  is  founded  are,  the 
period  of  incubation,  the  presence  or  absence  of  induration,  and  the 
condition  of  the  anatomically  related  lymphatic  glands.  Even  should 
ah  these  point  to  syphihs,  an  absolute  opinion  should  not  be  given 
until  it  is  justified  by  the  appearance  of  some  of  the  constitutional 
phenomena  which  in  from  six  to  eight  weeks  follow  chancre. 

Difficulties  of  diagnosis  are  greatest  during  the  first  week  or  ten 
days,  and  steadily  diminish  with  the  age  of  the  lesion,  which,  if 
syphilitic,  is  almost  certain  to  show  the  characteristics  of  the  chancre. 
Confrontation  is  seldom  practicable.  The  history  of  incubation  is 
often  vague  and  uncertain,  and  the  development  of  the  lesion  is  rarely 
studied  attentively  by  the  patient. 

Induration  is  present  in  the  great  majority  of  chancres,  and  when 
typically  developed  is  almost  enough  to  justify  a  positive  diagnosis. 
Induration,  however,  may  fail  as  a  diagnostic  sign,  since — 1,  it  may 
be  absent  or  but  slightly  developed ;  2,  it  may  be  masked ;  3,  it  may 
be  present  in  non-specific  ulcers ;  4,  it  may  be  present  in  relapsing 
chancres. 

1.  Lesions  absolutely  without  induration,  and  yet  followed  by 
secondary  syphihs,  have  been  reported  by  competent  observers. 
More  frequently  the  induration  is  so  slight  as  to  be  readily  confounded 
with  ordinary  inflammatory  infiltration.  Thus  the  initial  lesion  some- 
times appears  as  an  infecting  balanoposthitis,  differing  from  ordinary 
balanoposthitis  only  in  thickening  and  hardening  of  the  prepuce,  but 
slightly  greater  than  that  observed  as  a  result  of  simple  untreated 
inflammation ;  or  syphilis  may  be  inaugurated  by  the  multiple  her- 
petiform  chancre,  which  may  become  indurated  to  only  a  moderate 
degree.  On  the  glans  penis  the  induration  is  often  developed  not 
much  more  markedly  than  is  common  in  the  case  of  chancroids. 

In  the  genital  chancres  of  women  the  induration  is,  as  a  rule,  poorly 
developed ;  it  is  rare  to  find  in  women  the  typical  cartilaginous 
hardening. 

2.  Induration  may  be  masked  by  cellular  infiltration  dependent 


SYPHILIS.  833 

upon  acute  inflammation  attacking  a  chancre,  or  may  be  entirely 
destroyed  by  a  rapid  phagedenic  process. 

3.  Certain  non-specific  sores  may  present  induration  so  like  that 
of  the  chancre  that  differential  diagnosis  founded  on  this  sign  alone 
cannot  be  made.  A  simple  sore  which  has  been  treated  by  caustics 
will  frequently  take  on  induration :  hence  it  should  be  a  rule  in  ex- 
amining such  cases  to  ask  the  patients  how  they  have  been  treated, 
and  thus  avoid  attaching  too  much  importance  to  an  apparently 
characteristic  induration.  A  forming  furuncle,  the  inflamed  orifice  of 
a  suppurating  vulvo-vaginal  gland,  a  tubercular  ulcer,  an  isolated  lesion 
of  scabies,  may  all  present  a  circumferential  induration  which  will 
make  immediate  diagnosis  impossible.  , 

4.  Finally,  the  so-called  relapsing  chancre,  generally  a  tertiary 
lesion,  may,  with  the  exception  of  the  inguinal  adenopathy,  exactly 
simulate  the  primary  sore  of  syphilis. 

The  involvement  of  the  anatomically  connected  lymphatic  glands 
is  absent  as  a  very  rare  exception,  and  when  typical  is  highly  char- 
acteristic.    It  must  be  borne  in  mind,  however,  that : 

1.  Many  non-syphilitic  patients  exhibit  hard,  movable  lymphatic 
tumors  in  both  groins :  hence  it  is  important  to  examine  a  suspected 
case  frequently,  to  determine  whether  or  not  the  enlargement  is  pro- 
gressive. 

2.  Simple  sores  sometimes  cause  enlargement  of  several  glands, 
with  very  slight  inflammatory  phenomena.  Occasionally,  from  mixed 
infection,  syphilitic  buboes  exhibit  marked  inflammatory  reaction. 

3.  In  very  rare  cases  chancre  may  be  followed  by  secondary 
syphilis  without  involvement  of  the  anatomically  related  lymphatic 
glands. 

The  Differential  Diagnosis  of  Genital  Chancre. — Since  ulcer- 
ative lesions  of  the  genitalia  may  be  due  to  a  variety  of  causes,  and 
since,  even  though  different  in  their  nature,  they  may  present  some 
features  in  common,  the  question  of  differential  diagnosis  becomes  one 
of  great  importance. 

To  distinguish  between  a  "  mixed  chancre'''  and  a  chancroid  or  simple 
venereal  ulcer  is  often  impossible.  Even  should  a  chancroid  be  ab- 
solutely typical  in  all  its  clinical  features,  it  is  not  safe  to  make  a 
positive  statement  that  syphilis  will  not  develop.  If,  in  spite  of  th^ 
favorable  course  of  a  simple  ulcer,  after  two  or  three  weeks  charac 
teristic  induration  develops,  and  in  another  seven  days  the  inguinal 
glands  on  both  sides  painlessly  enlarge  one  after  another,  the  proba- 
bility of  syphilis  and  chancroid  having  been  inoculated  at  the  same 
point   is   great.     Per  contra,  if  a  non-inflammatory  indurated   sore 

53 


834 


GEXITO-UEIXART  DISEASES   AXD   SYPHILIS. 


appears  at  an  interval  of  more  than  ten  days  after  exposure,  and  in 
consequence  of  further  exposure  rapidly  assumes  an  inflammatory 
type,  sloughs,  and  extends  beyond  the  area  of  induration,  destroying 
the  latter,  and  presenting  on  examination  only  the  features  of  the 
simple  venereal  sore,  the  probahility  is  that  the  lesion  is  a  mixed 
chancre,  the  chancroidal  virus  having  been  inoculated  upon  the 
primary  lesion.  Tliis  probability  is  made  still  stronger  if  painless 
multiple  enlarged  lymphatic  glands  are  found  in  the  groins.  Even 
should  a  suppurating  bubo  form,  this  should  not  influence  the  diag- 
nosis m  regard  to  syphilis,  since  each  disease  will  run  its  course 
independent  of  the  other. 

The  differential  diagnosis  between  chancre,  chancroid,  aside  from  the 
microscopic  identification  of  the  Tryponema  or  the  Ducrey  bacillus, 
and  herpes  will  depend  upon  a  consideration  of  the  characteristics  of 
each  as  Q-iven  in  the  following  table  : 


Chancre. 

Origin. — ^Due  to  inocula- 
tion with  the  blood  or 
lesion-discharges  of  a 
syphilitic. 


Incuhaiion. — From  ten 
days  to  eight  -weeks. 
Average  about  three 
weeks. 

Situation. — Generally  on 
the  genitalia.  Often  on 
lips,  nipples,  and  hands. 


Number. — Single ;  at  times 
simultaneously  multi- 
ple. 

Beginning. — Begins  as  an 
erosion,  papule,  tuber- 
cle, or  ulcer.  May  re- 
main without  ulcera- 
tion through  its  entire 
course. 


Chancroid. 

Due  to  inoculation  with 
the  discharge  of  a  chan- 
croidal sore.  Possibly 
caused  by  pus  from 
other  sources. 


No  definite  period.  It 
may  not  be  noticed  for 
two  or  three  days. 

Generally  on  the  glans 
penis  and  the  prepuce. 
Rarely  on  other  geni- 
tal surfaces.  Hardly 
ever  on  other  parts  of 
the  body. 

Frequently  multiple,  often 
on  apposing  surfaces  by 
auto-inoculation. 

Begins  as  a  pustule  or  an 
ulcer.  Always  ulcer- 
ates. 


Herpes. 

Due  to, — 

(1)  Mechanical  irritation, 
as  in  sexual  intercourse. 

(2)  Chemical  irritation, 
such  as  is  produced  by 
acrid  discharges  or  by 
uncleanliness. 

(3)  To  neuroses  ;  often 
following  fever,  and 
particularly  occurring 
in  syphilitics. 

None. 


Generally  on  the  glans 
penis  and  the  inner 
layer  of  the  prepuce. 


Multiple.  Ultimately  often 
confluent. 

Begins  as  a  group  of  vesi- 
cles, which  may  coa- 
lesce or  may  ulcerate 
singly. 


SYPHILIS. 


835 


Chancre. 

Shape. — Round,  oval,  or 
symmetrically  irregu- 
lar. 


Chancroid. 


Rough,  uneven,  "  worm- 
eaten,"  warty,  grayish, 
pultaceous  slough. 


Abundant,  purulent,  read- 
ily auto-inoculable. 


r>epth. — Usually  superfi- 
cial, cup-shaped  or  sau- 
cer-shaped, or  may  be 
elevated. 

Surface. — Smooth,  shin- 
ing, dusky  red,  glazed; 
diphtheritic  membrane, 
or  scab  or  epithelial 
crusts. 

Secretion. — Scanty,  serous, 
hardly  ever  auto-in- 
oculable, except  in 
cases  of  mixed  infec- 
tion, when  a  chan- 
croidal sore  may  be  pro- 
duced. On  squeezing 
cannot  press  out  a  dis- 
charge. 

Induration. — Almost  al- 
ways present ;  firm, 
cartilaginous,  or  parch- 
ment-like ;  sharply  cir- 
cumscribed; movable 
upon  subjacent  parts. 
Prolonged  pressure  by 
the  examining  fingers 
does  not  produce  any 
change  in  it;  usually 
persistent ;  disappears 
under  specific  treat- 
ment. 

Sensibility. — Very     rarely      Often  painful 
painful. 

Course. — Progressively  to- 
wards cure,  the  sore 
often  healing  spontane- 
ously. Relapses  and 
phagedaena  uncommon. 


Round,  oval,  or   unsym- 

metrically       irregular, 

with  border   described 

by  segments    of   large 

circles. 
Hollow,     excavated,     or      Superficial. 

"  punched  out." 


Herpes. 

Irregular,  circinate  bor- 
ders, representing  seg- 
ments of  small  circles ; 
sometimes  serrated. 


Only  exceptionally  pres- 
ent. Due  to  caustics  or 
other  irritants,  or  to 
simple  inflammation ; 
boggy,  inelastic,  shades 
off  into  surrounding 
parts,  to  which  it  is  ad- 
herent ;  disappears  soon 
after  cicatrization.  Pro- 
longed pressure  causes 
changes  in  shape,  such 
as  are  noted  in  oedema. 


Irregular ;  may  cicatrize 
rapidly  or  may  extend. 
Relapses  and  phage- 
daena not  uncommon. 


Bright  red  superficial 
granulations,  some- 
times covered  by  diph- 
theritic membrane. 

Moderate  secretion,  auto- 
inoculable  with  diffi- 
culty. On  squeezing  a 
small  serous  drop  ex- 
udes. When  this  is 
wiped  away,  another 
drop  can  be  pressed  out. 
This  can  be  repeated 
several  times. 

Same  as  local  ulcer. 


Often  painful. 

Easily  and  quickly  cured. 
Sometimes  spreads  by 
the  appearance  of  suc- 
cessive crops  of  vesi- 
cles. Lesions  preserve 
the  polycyclic  form. 
Likely  to  recur,  espe- 
cially in  syphilitics  and 
in  uncleanly  patients 
with  Ion?  foreskins. 


836 


GENITO-UKHSTAEY   DISEASES   AND  SYPHILIS. 


Chancre. 

Histology. — A  new  cell 
growth.  Very  little  de- 
struction of  tissue. 
Scrapings  often  show 
more  or  less  epithelium. 

Bubo.  —  Constant,  pain- 
less, multiple,  generally 
bilateral. 


Prognosis. — Good  locally  ; 
ulceration  is  at  the  ex- 
pense of  the  infiltrate : 
hence  there  is  little  ul- 
timate scarring ;  consti- 
tutional syphilis  follows 
in  the  great  majority  of 
cases.  In  a  few  it  may 
not  appear,  or  may  be 
prevented  from  appear- 
ing by  treatment. 

Treatment. — Excision 
when  seen  early  ;  other 
purely  local  treatment 
is  ineffective. 


Chancroid. 
An  ulceration,  with  more 
or  less  loss  of  substance. 
Scrapings  show  granu- 
lation-tissue. 

Appears  only  in  one-third 
of  the  cases ;  painful, 
inflammatory,  single, 
or  a  single  one  on  each 
side. 

More  serious  locally,  for 
there  is  tissue  destruc- 
tion. May  refuse  to 
heal  or  may  become 
phagedenic.  Never  fol- 
lowed by  syphilis 
(unless  mixed). 


Local  treatment  is  cura- 
tive. 


Herpes. 
Originally    an    elevation 
of    the     epidermis    in 
spots  by  an  eifusion  of 
serum. 

Rare.  When  it  does  oc- 
cur, painful,  inflamma- 
tory, single,  or  a  single 
one  on  each  side. 

Always  good.  Recur- 
rences are  frequent,  es- 
pecially in  syphilitics. 
(The  herpetic  chancre 
closely  simulates  her- 
pes.) 


Local  treatment  is  cura- 
tive. Tendency  to  spon- 
taneous cure. 


When  phimosis  is  present,  so  that  a  lesion  of  the  glans  or  of  the 
under  surface  of  the  foreskin  cannot  be  exposed,  it  is  exceedingly 
difficult  to  determine  whether  such  a  lesion  is  chancrous  or  is  due 
to  inflammatory  processes  of  a  different  nature.  In  such  cases  a 
diagnosis  must  be  made  after  a  consideration  of  the  following  points 
of  difference : 

Subpreputial  Chancre. 

Incubation. — Never  less  than  ten  days. 

Usually  three  weeks ;  may  be  more. 


Number. — ^The  lesion  is  usually  single. 

(This  may  be  learned  from  the  history 

of  the  case  before  phimosis  developed, 

or  from  palpation.) 
Inflammation. — Acute  symptoms  absent 

or  but  slightly  marked. 

Swelling. — Hard,  characteristic  circum- 
scribed induration.  Can  often  be 
isolated  from  surrounding  tissues  and 
raised  ^.nd  felt  between  the  thumb 
and  finger. 


Non-Syphilitic  Subpreputial  Ulceration. 

Incubation. — Really  none.  Inflamma- 
tory symptoms  become  pronounced 
in  less  than  ten  days. 

Number. — The  lesions  are  usually  mul- 
tiple. 


Inflammation. — Acute  symptoms  very 
pronounced.  (Heat,  swelling,  pain, 
redness.) 

Swelling. — Diffuse,  oedematous,  general 
inflammatory  infiltration.  Cannot  be 
isolated  or  felt  as  a  circumscribed  in- 
duration. 


SYPHILIS.  837 

Subpreputial  Chancre.  Non-Syphilitic  Subpreputial  Ulceration. 

Discharge. — Moderate,    thin,    at    times  Discharge. — Often  produces  auto-inocu- 

blood-stained.     Not   readily   auto-in-  lation  by  accidental  contact. 

oculable. 

Preputial  Orifice. — Not  markedly  ulcer-  Preputial     Orifice. — Almost    invariably 

ated.  ulcerated. 

Buboes. — Non-inflammatory,     bilateral,  Buboes. — Single,   inflammatory,  suppu- 

inguinal  buboes  always  develop.  rating  buboes  often  develop. 

Concealed  Genital  Chancres. — Typical  chancre  may  develop  about 
the  genitalia,  yet  from  the  fact  that  it  is  so  placed  as  to  be  concealed 
from  view  it  may  not  be  observed ;  thus  chancres  of  the  cervix  uteri 
and  chancres  of  the  urethra  are  not  usually  recognized  as  such  till 
constitutional  symptoms  develop. 

Chancre  of  the  cervix  uteri  is  probably  more  common  than  is 
generally  beheved.  It  is  often  not  discovered  because  the  lesion  thus 
placed  produces  no  pain  and  but  very  slight  discharge :  hence  there 
are  no  symptoms  which  would  lead  a  patient  to  present  herself  for 
examination. 

The  chancre  is  nearly  always  situated  at  the  margin  of  the  os,  and 
presents  the  same  variations  in  size  and  surface  as  are  noted  in 
primary  sores  of  the  external  genitalia.  It  may  appear  as  an  erosion, 
as  a  deep  ulceration  with  a  smooth  pseudo-membranous  surface,  or  as 
a  papillary  outgrowth.  It  may  be  no  larger  than  a  split  pea,  or  may 
present  a  raw  surface  the  size  of  the  thumb-nail.  Induration,  though 
present,  cannot  be  felt,  owing  to  the  position  of  the  lesion.  Chancre 
of  the  cervix  must  be  distinguished  from  ulcerating  folliculitis,  from 
mechanical  erosions  and  ulcerations,  from  herpes,  and  at  times  from 
malignant  growths. 

Ulcerating  folhculitis  is  commonly  associated  with  a  chronic 
catarrhal  condition,  and  produces  small,  often  multiple  lesions,  ex- 
tending very  little  beyond  the  limits  of  the  follicle.  These  lesions 
promptly  heal  under  appropriate  treatment. 

Mechanical  erosions  and  ulcerations  may  closely  simulate  the  spe- 
cific lesion,  but  are  less  sharply  circumscribed  and  do  not  show  the 
characteristic  regular  development  of  the  specific  sore. 

Herpetic  lesions  can  be  distinguished  from  chancre  of  the  cervix 
by  the  fact  that  the  former  are  usually  multiple,  often  coalesce,  pre- 
senting a  circinate  margin  formed  of  the  segments  of  many  circles, 
and  heal  rapidly. 

Cancer  occurs  at  an  age  when  chancre  is  not  common ;  its  course 
is  often  painful  and  always  progressive.  It  causes  deep  ulceration  and 
steadily  infiltrates  surrounding  tissues.     If  at  first  glance  a  chancre 


838  GENITO-UKINAEY  DISEASES   AND   SYPHILIS. 

resembles  cancer,  the  further  progress  of  the  case  will  shortly  decide 
the  diagnosis. 

Chancre  of  the  Meatus. — When  the  sore  involves  the  meatus  it 
looks  more  like  a  chancroid  than  like  a  chancre.  (Fig.  256.)  From 
frequently  repeated  irritation  incident  to  the  flow  of  urine,  the  lesions 
become  distinctly  inflammatory  in  type  ;  they  are  ulcerative  and  de- 
structive, showing  jagged,  punched-out  borders,  and  but  moderate 
induration,  best  detected  by  taking  the  end  of  the  glans  between  the 
thumb  and  the  forefinger  and  squeezing  it  in  an  antero-posterior  direc- 
tion. Permanent  cicatricial  deformity  is  often  left  after  they  have 
healed.  Chancre  is  perhaps  more  prone  to  develop  at  the  meatus 
than  is  chancroid :  hence  a  sore  in  this  region  should  be  suspected, 
even  though  it  exhibits  none  of  the  clinical  features  of  the  syphilitic 
lesion. 

Urethral  chancre  is  often  overlooked,  not  because  of  absence  of 
characteristic  features,  but  rather  because  the  lesion  in  this  locality  is 
so  rare  that  methodical  search  is  not  made  for  it.  As  would  naturally 
be  expected,  the  chancre  is  generally  at  or  near  the  meatus.  It  is 
rarely  placed  farther  back  than  the  fossa  navicularis.  (See  Syphilitic 
Urethritis.) 

EXTRAGENITAL   CHANCRE. 

Errors  or  difficulties  in  diagnosis  may  arise  from  the  fact  that  a 
chancre  is  extragenital. 

As  a  rule,  chancroid  is  found  only  about  the  genital  organs  :  hence 
in  other  regions  the  question  of  distinguishing  between  this  sore  and 
chancre  rarely  comes  up.     The  extragenital  lesion  is  usually  single. 

Its  favorite  seats  have  been  given. 

Herpetiform  erosions  of  the  lips,  papules  on  the  tip  of  the  tongue, 
scabby  ulcerations  of  the  skin,  scratches  which  absolutely  refuse  to 
heal,  chronic  inflammations  at  the  tips  of  the  fingers,  resembling  felons, 
but  without  the  accompanying  acute  inflammatory  symptoms, — all 
such  lesions  should  be  regarded  with  suspicion  if  indolent  in  course, 
obstinate  to  treatment,  and  accompanied  by  slight  discharge  which 
has  a  tendency  to  form  crusts  or  a  pseudo-membranous  deposit  on  the 
eroded  surface.  If,  moreover,  such  lesions  are  placed  upon  an  elastic, 
sharply  circumscribed,  indurated  base,  and  are  followed  by  hard,  pain- 
less enlargement  of  the  nearest  associated  group  of  lymphatic  glands, 
the  diagnosis  receives  strong  corroboration.  It  is  made  absolutely 
certain  by  finding  the  Tryponemata. 

Chancres  of  the  Head  and  Face. — Razor-cuts  on  the  chin,  cheeks 
or  lips  which,  after  having  healed,  reopen  and  become  covered  with 
crusts,  pseudo-furuncles  or  acneiform  pustules,  and  cracks  around  the 


SYPHILIS. 


839 


mouth  or  nose  which  persist,  are  painless,  are  surrounded  by  an  area 
of  inflammatory  oedematous  swelling,  and  give  a  thin,  blood-stained 
discharge  which  exhibits  a  tendency  to  form  crusts,  should  suggest 
the  possibility  of  chancre,  and  should  lead  to  frequently  repeated 
examination  of  the  parotid  and  submaxillary  lymphatic  glands.  The 
primary  sore  of  syphilis  when  it  occurs  on  the  scalp  or  on  the 
bearded  cheeks  or  chin  closely  resembles  ecthyma.  On  removing 
the  surrounding  and  covering  hair,  a  glazed,  flat,  slightly  elevated 
superficial  ulceration  is  detected.  When  a  patient  presents  himself 
with  such  lesion  it  is  often  impossible  from  the  local  signs  to  deter- 

FiG.  259. 


Chancre  of  the  lip. 

mme  whether  or  not  the  sore  is  specific.  The  syphilitic  lesion 
begins  as  a  papule  or  an  erosion,  which  slowly  extends,  is  attended 
with  distinct  induration,  is  never  actively  inflammatory  in  type,  causes 
painless  enlargement  and  hardening  of  the  nearest  lymphatic  glands, 
and  is  followed  by  secondary  symptoms.  The  ecthymatous  lesion 
begins  as  a  flat  pustule,  surrounded  by  an  acute  inflammatory  but 
non-indurated  base,  is  generally  multiple,  and  runs  its  course  in  two 
or  three  weeks. 

The  eyelids  and  the  ocular  conjunctiva  may  be  the  seat  of  primary 
sore.  The  lesion  begins  as  a  papule,  which  graduahy  becomes  in- 
durated and  eroded  or  ulcerated,  presenting  the  characteristic  sloping 
edges  and  hard  base  of  chancre.     This  lesion  has  often  been  mistaken 


840 


GENITO-UPvIXARY    DISEASES   AND   SYPHILIS. 


for  a  stye  ;  its  development  and  the  absence  of  acute  inflammatory 
symptoms  would  make  a  correct  diagnosis  possible  in  a  very  few 
days.  Lymphatic  enlargement  is  first  noted  in  the  glands  in  front 
of  the  ear  and  at  the  angle  of  the  jaw. 

At  times  chancre  of  the  head  and  face  attains  enormous  size, 
differing  entirely  in  appearance  from  the  primary  lesion  of  syphilis 
as  ordinarily  observed ;  induration  may  be  absent,  and  occasionally 
acute  inflammatory  symptoms  are  pronounced.  In  such  cases  a 
positive  diagnosis  can  be  made  only  by  recognizing  the  characteristic 
lymphatic  enlargement  and  the  development  of  secondary  lesions. 

Chancre  of  the  Lip. — As  is  the  case  in  chancre  of  other  extra- 
genital regions,  chancre  of  the  lip  in  its  beginning  closely  simulates 

Fig.  260. 


Chancre  of  the  lip. 


ordinary  non-specific  sores.  It  often  begins  as  a  chap  or  fissure, 
frequently  found  in  the  median  line  as  an  aphthous  lesion,  an  herpetic 
ulceration,  or  an  ulceration  such  as  would  be  produced  by  the  burn 
of  a  cigar  or  of  a  cigarette.  In  the  early  stage  there  is  nothing  char- 
acteristic about  these  lesions,  but  in  a  few  days  the  extension  of  the 
erosion  or  ulcer  and  the  formation  of  a  characteristic   and  usually 


SYPHILIS. 


841 


very  pronounced  and  extensive  induration  indicate  the  nature  of  the 
affection.  (Fig.  259.)  The  diagnosis  is  made  still  more  positive  in 
the  course  of  one  or  two  weeks  by  enlargement  of  the  submental 
lymphatic  glands. 

The  whole  lip  is  generally  congested  and  swollen,  sometimes 
reaching  an  enormous  size.  (Fig.  260.)  At  times  the  induration  of  lip 
chancre  is  so  great  and  the  ulcerating  process  so  marked  that  on  first 
inspection  it  seems  to  be  malignant.  The  fact  that  chancres  have  been 
excised  because  they  were  mistaken  for  epitheliomata,  thus  entailing 
on  a  patient  unnecessary  mutilation,  justifies  a"  tabulation  of  the  points 
of  difference  between  the  two  affections,  by  a  consideration  of  which 
the  nature  of  each  may  be  correctly  determined. 


Labial  Chancre. 

History. — Sometimes   a  history   of  ex- 
posure to  syphilitic  inoculation. 
Age. — Occurs  at  any  age. 

6*1?^:. — Affects  males  and  females  indiffer- 
ently. 

Seat. — Involves  either  lip. 

Local  Symptoms.— K  painless  elevated 
sore,  regular  in  outline,  with  a  smooth 
surface  and  a  sharply  circumscribed, 
dense  induration.  A  scanty,  odor- 
less discharge. 

Course. — The  sore  develops  in  a  few 
weeks  at  most,  often  in  from  seven 
to  ten  days.  It  is  followed  in  one  or 
two  weeks  by  submaxillary  glandular 
enlargements,  and  in  from  six  to  eight 
weeks  by  secondary  symptoms. 

Therapeutic  Test. — Mercury  causes  the 
prompt  disappearance  of  the  chancre. 

Microscopic  Examination. — The  chancre 
shows  a  small,  round-celled  infiltrate, 
particularly  along  the  course  of  the 
blood-vessels. 


Labial  Epithelioma. 

History. — Sometimes  a  history  of  cancer 

in  the  family. 
Age. — Occurs  near-ly  always  after  middle 

life. 
Sex. — Hardly  ever  affects  females. 

Seat. — Almost  always  involves  lower  lip. 

Local  Symptoms. — An  irregular,  ragged, 
often  painful  sore,  bleeding  easily,  and 
irregularly  indurated.  An  offensive 
discharge. 

Course. — -The  sore  develops  very  slowly, 
— a  matter  of  months.  The  glands 
are  involved  only  after  several  months. 


Therapeutic  Test. — Mercury  has  no  bene- 
ficial effect  upon  the  epithelioma. 

Microscopic  Examination. — The  epitheli- 
oma shows  the  pearly  bodies. 


Chancre  of  the  Tongue. — The  primary  lesion  of  syphilis  is  less 
common  on  the  tongue  than  on  the  lips.  It  usually  involves  the  an- 
terior half  of  the  organ,  and  is  found  on  the  dorsal  surface,  the  sides, 
or  the  tip. 

It  commonly  assumes  the  erosive  form,  presenting  an  appearance 
almost  identical  with  that  of  similar  genital  lesions.     There  is  simply  a 


842  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

painless,  oval,  or  rounded  superficial  lesion,  with  smooth  surface, 
frequently  covered  by  a  grayish  pseudo-membrane  seated  upon  a 
parchment-like  induration.  (Figs.  261,  262.)  It  is  often  as  large  as  a 
ten-cent  piece.  The  supra-hyoidean  and  sometimes  the  submental 
glands  first  exhibit  the  specific  enlargement.  Fournier  states  that 
when  the  tip  of  the  tongue  is  involved,  glandular  enlargement  is  at 
times  noted  just  behind  the  symphysis  of  the  lower  jaw. 

The  ulcerative  form  of  lingual  chancre  exhibits  a  deep  lesion,  often 
upward  of  an  inch  in  diameter,  with  sloping  edges,  and  dense,  well- 
marked  induration. 

However  easy  the  diagnosis  may  be  when  the  chancre  is  well 
developed,  in  the  first  stages  lingual  chancres  simulate  non-specific 
lesions  so  closely  that  mistakes  very  readily  occur.  An  early  diag- 
nosis is  extremely  important  in  such  cases,  since  failure  to  recognize 
the  syphilitic  nature  of  the  disease  may  result  in  its  transmission  to 
healthy  persons.  If  an  ulceration  apparently  produced  by  carious 
teeth,  or  a  papule  arising  without  given  cause,  fails  to  heal  in  five  or 
six  days,  but,  on  the  contrary,  enlarges,  becomes  elevated,  is  eroded, 
is  covered  with  pseudo-membrane,  and  is  not  made  better  by  appli- 
cations of  silver  nitrate,  the  lesion  may  be  looked  on  with  great  sus- 
picion, which  will  deepen  into  almost  certainty  with  the  appearance 
of  induration  and  glandular  enlargement. 

Chancre  of  the  Tonsils  and  Fauces. — Chancre  is  rare  in  these 
regions,  and  when  observed  is  so  masked  by  concomitant  inflam- 
matory symptoms  that  diagnosis  is  usually  impossible.  The  lesion  as 
described  presents  the  appearance  of  a  mucous  patch,  which  is  single, 
and,  if  it  can  be  palpated  by  one  finger  in  the  pharynx  and  the  other 
external  to  its  walls,  is  found  to  be  indurated.  There  is  a  history  of 
prolonged  sore  throat,  and  in  one  or  two  weeks  the  glands  at  the 
angle  of  the  jaw  enlarge. 

Primary  syphilis  of  the  tonsil  is  observed  in  women  much  more 
frequently  than  in  men. 

Chancre  of  the  Breast. — The  lesion  is  usually  caused  by  a 
syphilitic  infant  nursed  by  a  healthy  woman :  hence  it  is  in  women 
that  it  is  nearly  always  observed,  though  a  few  cases  have  been  re- 
ported in  men,  with  a  different  etiology. 

The  sore  may  appear  either  about  or  upon  the  nipple,  or  upon 
the  skin  covering  the  mammary  gland.  In  the  latter  case  it  usually 
exhibits  the  characteristic  features  of  chancre  as  found  on  the  geni- 
talia, being  commonly  of  the  erosive  or  the  ulcerative  type  and  rarely 
offering:  diagnostic  difficulties. 


Fig.  261. 


Chancre  of  the  tongue. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


Fig.  262. 


Chancre  of  the  tongue- 


Fig.  263. 


Chancre  of  the  hand 


SYPHILIS.  .  843 

When  the  lesion  is  situated  on  the  nipple  or  at  its  base,  the  diag- 
nosis may  be  a  matter  of  very  great  difficulty.  As  is  the  case  with 
chancre  about  the  nose  and  mouth,  the  sore  very  closely  simulates 
non-specific  affections,  such  as  simple  fissure,  mechanical  erosion  or 
ulcer,  or  even  beginning  eczema.  If,  hov^ever,  a  lesion  so  apparently 
simple,  instead  of  healing  under  treatment,  slowly  extends,  if  it  is 
accompanied  by  little  or  no  pain,  if  it  gives  a  scanty,  blood-stained 
discharge  which  has  a  tendency  to  crust,  and,  most  important  of  all, 
if  it  exhibits  distinct  induration  and  painless,  non-inflammatory  lym- 
phatic enlargement  in  the  axilla,  the  diagnosis  of  chancre  can  be  made 
with  some  certainty. 

Suspicious  lesions  in  a  nursing  woman  should  at  once  suggest 
an  examination  of  the  child  she  suckles.  Secondary  lesions  in  the 
mouth  of  the  latter  would  constitute  almost  positive  evidence  as  to 
the  syphilitic  nature  of  the  breast  lesions  in  the  woman,  provided  she 
is  not  the  mother  of  the  diseased  child  (Colles's  immunity). 

Chancres  of  the  Anal  Region. — Chancres  of  the  anus  are  much 
more  common  in  women  than  in  men.  This  is  due  not  necessarily 
to  unnatural  practices,  but  rather  to  the  fact  that  in  the  dorsal  decu- 
bitus the  vaginal  discharges  flow  downward  over  the  perineum  and 
the  anus  and  thus  inoculate  the  cracks  or  abrasions  which  may  exist 
in  those  regions. 

The  sore  is  usually  placed  at  the  anal  margin,  in  one  of  the  muco- 
cutaneous folds  or  puckerings  incident  to  the  normal  contraction  of 
the  external  sphincter.  The  ulceration  often  follows  the  line  of  these 
folds,  thus  producing  an  elongated  or  linear  lesion  ;  this  becomes  in- 
durated, gives  a  scanty  discharge,  is  not  painful,  is  refractory  to  local 
treatment,  and  is  generally  followed  by  characteristic  enlargement  of 
the  inguinal  glands. 

In  place  of  the  indurated  linear  ulcer,  an  anal  chancre  may  appear 
as  an  excoriated  papule,  or,  more  rarely,  as  a  typical  cup-shaped, 
densely  indurated,  ulcerating  chancre. 

From  the  appearance  of  the  anal  lesion  it  is  sometimes  very  diffi- 
cult to  determine  whether  it  is  a  fissure,  or  a  simple  ulcer,  or  the 
primary  sore  of  syphihs.  The  slow,  progressive  development  of  the 
chancre,  and  the  absence  of  pain  and  of  spasm  of  the  sphincter,  will 
indicate  the  specific  nature  of  the  affection,  even  before  induration  and 
lymphatic  involvement  make  the  diagnosis  almost  positive.  Chancres 
of  the  rectum  are  exceedingly  rare. 

Chancres  of  the  Extremities. — Chancre  is  occasionally  observed 
on  the  thighs,  the  anterior  surface  in  men  and  the  posterior  surface 
in  women  being  the  regions  of  preference,  on  the  antero-lateral  sur- 


844  GENITO-UEINAKY   DISEASES   A:N^D   SYPHILIS. 

faces  of  the  forearm  in  both  sexes,  and  particularly  on  the  fingers  at 
the  margins  of  the  nails.  Occasionally  it  develops  over  a  knuckle, 
having  been  inoculated  through  a  wound  caused  by  a  blow  on  the 
teeth  of  a  syphilitic.  (Fig.  263.)  Except  on  the  fingers,  the  chancre 
develops  in  a  characteristic  manner  and  offers  no  special  diagnostic 
difficulties. 

Digital  chancres  commonly  appear  at  the  edges  or  the  base  of  the 
nail,  starting  as  erosions,  papules,  or  pustules,  becoming  indurated, 
elevated,  and  ulcerated,  being  accompanied  by  much  swelling  of  the 
surrounding  finger-pulp,  and  presenting  the  appearance  of  an  ulcer- 
ating felon. 

The  chancre,  however,  develops  slowly,  is  not  extremely  painful, 
discharges  but  little,  is  not  favorably  influenced  by  local  treatment, 
and  is  shortly  followed  by  epitrochlear  and  axillary  glandular  enlarge- 
ment. When  the  lesion  involves  the  ring  or  the  little  finger,  the 
gland  at  the  elbow,  if  present,  is  enlarged ;  the  lymphatics  from  the 
thumb  and  from  the  index  and  middle  fingers  pass  directly  to  the 
axillary  gland. 

Sometimes  the  chancre  may  develop  so  insidiously  and  may  form 
so  insignificant  a  lesion,  simply  a  small  indurated  papule,  that  even 
the  patient's  attention  is  not  directed  to  it,  and  he  has  no  suspicion 
of  having  acquired  syphilis  till  the  secondary  lesions  appear. 

The  early  diagnosis  of  digital  chancre  is  often  a  matter  of  very 
great  importance,  since  a  mistake  may  readily  lead  to  neglect  of  pre- 
cautions which  would  prevent  the  disease  from  being  conveyed  to 
healthy  persons.  This  is  particularly  important  with  doctors  and 
nurses,  who  form  the  class  in  which  digital  chancres  are  observed. 
Any  painless  lesion  about  the  fingers  giving  a  scanty  discharge,  steadily 
enlarging  in  spite  of  treatment,  and  becoming  distinctly  hard,  should 
excite  suspicion,  and  should  lead  to  a  careful  examination  for  the 
Tryponema. 

Vaccination  Chancre. — When  bovine  virus  is  used,  vaccination 
syphilis  from  the  lymph  is  an  impossibility.  When,  however,  human 
lymph  is  employed,  this  accident  has  occurred  many  times.  If  the 
vaccination  takes,  the  pustule  may  run  the  typical  course,  and  may  be 
healed  before  evidences  of  the  chancre  appear.  More  commonly  the 
healing  of  the  ulcer  resulting  from  the  vaccinal  suppuration  is  de- 
layed ;  it  presents  a  smooth  surface,  gives  a  very  scanty  discharge, 
is  unattended  by  pain,  and  characteristic  induration  develops.  The 
associated  lymphatic  glands  are  enlarged,  and  secondary  symptoms 
follow. 


SYPHILIS.  845 

If  the  vaccination  does  not  take,  there  may  be  no  sign  of  trouble 
for  fifteen  to  thirty  days.  Then  an  indurated  papule  is  formed,  which 
slowly  ulcerates  and  offers  all  the  peculiarities  of  erosive  or  ulcerative 
chancre.  Sometimes  the  vaccination  ulcer  becomes  acutely  inflamed, 
even  phagedenic,  the  inflammatory  symptoms  thus  masking  the 
syphilitic  nature  of  the  lesion :  simple  vaccinal  phagedenism  may, 
however,  present  some  of  the  features  of  an  inflamed  chancre.  The 
prompt  yielding  of  the  former  to  local  treatment  should  estabhsh  a 
correct  diagnosis  in  a  few  days. 

The  Prognosis  of  Chancre. — Usually  in  three  or  four  weeks, 
sometimes  in  as  many  months,  the  chancres  become  cicatrized,  the 
induration  disappears,  and  there  is  left  a  brownish  scar,  which  may 
persist  for  years.  This  scar  may  retain  its  pigmentation  as  long  as  it 
remains  perceptible  ;  more  commonly  it  becomes  white. 

Healing  of  the  chancre  will  take  place  spontaneously,  but  will  be 
greatly  accelerated  when  mercury  is  administered.  Even  in  extensive 
ulcerating  chancres,  such  as  are  observed  on  the  cheeks  or  the  lips,  for 
instance,  there  is  almost  no  ultimate  deformity,  since  the  destruction 
of  tissue  is  mainly  at  the  expense  of  the  syphilitic  infiltrate.  If  the 
chancre  is  attacked  by  phagedsena, — which  is  rare, — and  if  the  slough- 
ing process  destroys  the  induration  and  passes  wide  of  its  limits,  there 
may  be  resultant  cicatricial  deformity,  but  this  will  be  due  not  to  the 
specific  poison,  but  to  the  destructive  influence  of  other  microbes. 

Chancre  of  the  conjunctiva  may  give  rise  to  grave  ophthalmia. 

Chancre  of  the  tongue  or  of  the  fauces  may,  through  interference 
with  mastication  or  deglutition,  cause  great  debility,  and  chancre  of 
the  urethra  is  frequently  followed^by  stricture. 

The  prognosis  of  syphilitic  chancre  considered  as  a  local  disease 
iSf  then,  almost  uniformly  favorable.  As  to  any  relation  existing  be- 
tween the  source  of  contagion,  the  chancre,  and  the  constitutional 
disease  of  which  it  is  the  precursor,  the  following  chnical  facts  seem 
well  established : 

1.  It  is  impossible  to  predict  the  form  of  chancre  from  the  charac- 
ter of  the  source  of  infection.  It  is  well  known  that  the  most  widely 
differing  forms  of  initial  lesion  may  be  acquired  from  the  same 
individual. 

2.  The  severity  of  the  constitutional  disease  bears  no  relation  to 
the  form  of  the  initial  lesion.  A  dry  papule  may  be  followed  by 
severe  secondary  symptoms,  while  an  ulcerating  chancre  may  precede 
a  very  slight  form  of  constitutional  involvement. 

3.  A  short  primary  incubation  has  been  shown  experimentally  to 
be  indicative  of  a  strong  tissue  resistance  against  the  disease. 


846  GENITO-UEINAEY   DISEASES   AND    SYPHILIS. 

4.  The  amount  of  glandular  implication  is  as  uncertain  a  prog- 
nostic guide,  in  regard  to  the  severity  of  the  constitutional  disease, 
as  is  the  type  of  chancre. 

The  treatment  of  chancre  is  fully  described  under  the  abortive 
treatment  of  syphilis.     (See  pages  1005-1043.) 

Primary  Lymphatic  Involvement. — Coincident  with  the  de- 
velopment of  the  chancre  there  is  a  marked  alteration  in  the  asso- 
ciated lymphatic  vessels  {lymphangitis)  and  glands  {lymphadenitis  or 
huho). 

Syphilitic  Lymphangitis. — In  about  twenty  per  cent,  of  genital 
chancres  there  develops  usually  within  the  first  week,  and  before  the 
lymphatic  glands  are  involved,  a  painless,  often  beaded  hardening 
of  the  lymphatic  vessels  of  the  dorsum  of  the  penis.  They  form  a 
cord  about  the  size  of  a  match-stick,  and  may  be  felt  starting  from 
the  region  of  the  chancre  and  running  up  as  far  as  the  inguinal  glands, 
though  the  hardening  does  not  often  extend  more  than  two  or  three 
inches  along  the  back  of  the  penis.  Unless  there  is  mixed  infection, 
the  skin  over  these  lymphatic  vessels  does  not  become  discolored  or 
adherent ;  except  the  induration,  there  are  no  signs  of  inflammation. 
There  may  be  several  of  these  indurated  lymphatic  vessels,  forming 
small  distinct  cords. 

The  specific  lymphangitis  usually  subsides  with  the  induration  of 
the  chancre,— that  is,  within  from  three  to  five  weeks ;  though,  like 
the  latter,  it  may  last  for  several  months. 

The  lymphangitis  accompanying  extragenital  chancres  and  genital 
chancres  of  women  can  rarely  be  detected,  owing  to  the  less  accessi- 
ble position  of  the  involved  lymphatic  vessels. 

Syphilitic  Lymphadenitis  or  Bubo. — The  syphilitic  bubo  is,  after  the 
chancrous  induration,  the  most  characteristic  and  constant  feature  of 
primary  syphilis.  As  commonly  used,  the  term  syphilitic  bubo  is  ap- 
plied only  to  those  glands  with  which  the  lymphatic  vessels  from  the 
chancre  communicate  directly.  In  about  a  week  from  the  appearance 
of  the  chancre  these  glands  undergo  a  painless  enlargement.  Since 
chancres  are  usually  placed  upon  the  genitaha,  the  inguinal  glands  are 
the  ones  commonly  affected.  In  accordance  with  the  seat  of  chancre, 
the  bubo  will  be  placed  as  follows  : 

Genital  and  perigenital  chancres  (including  those  of  the  perineum 
and  anus)  involve  the  inguinal  glands ;  chancres  of  the  lip  and  chin 
mvolve  the  submaxillary  glands  ;  chancres  of  the  tongue  involve  the 
suprahyoid  or  submaxillary  glands  ;  chancres  of  the  eyelid  involve 
the  preauricular  glands  ;  chancres  of  the  fingers  involve  the  epi- 
trochlear  or  axillary  glands;  chancres  of  the  breast  involve  the 
axillary  glands. 


SYPHILIS.  847 

In  genital  chancre  the  gland  first  affected  is  usually  the  nearest 
one  of  the  chain  on  the  atfected  side,  though  when  the  lesion  is  situ- 
ated upon  the  side  of  the  fraenum  a  gland  of  the  opposite  side  may 
first  enlarge.  Subsequently,  one  after  the  other,  several  of  the  glands 
or  the  entire  chain  become  hypertrophied.  This  commonly  takes 
place  in  both  groins,  though  exceptionally  it  is  limited  to  one  side. 
On  examination  the  glands  are  felt,  each  distinct,  hard,  almond- 
shaped,  painless,  and  freely  movable. 

There  are  often  one  large  gland  and  a  group  of  from  three  to  five 
smaller  ones,  each  about  the  same  size.  Sometimes  but  a  single 
gland  is  enlarged ;  this  is  particularly  the  case  with  extragenital 
chancres,  such  as  those  of  the  lip.  The  enlargement  is  never  very 
great,  the  ganglia  rarely  exceeding  the  size  of  a  marble.  The  group 
of  typically  indurated  glands  of  the  groin  has  been  termed  the 
"  pleiade  ganglionnaire." 

Suppuration  occurs  in  these  glands  only  as  a  result  of  mixed  in- 
fection, the  pyogenic  microbes  gaining  access  through  the  surface 
break  caused  by  the  chancre. 

In  very  exceptional  cases  chancre  is  not  accompanied  by  syphilitic 
bubo. 

Diagnosis. — Since  lymphatic  vessels  and  glands  may  be  enlarged 
as  a  consequence  of  simple  inflammation,  and  since  the  syphilitic 
bubo  is  one  of  the  most  important  means  of  diagnosing  chancre,  it  is 
necessary  to  bear  in  mind  the  points  of  difference  between  syphilitic 
and  simple  inflammatory  involvement  of  the  lymphatics.  These 
points  of  difi'erence  are  as  follows ; 

Syphilitic  Lymphangitis.  Inflammatory  Lymphangitis. 

GzMse.— Always  a  chancre.  Cause. — Chancroids,   herpes,    or    other 

non-specific  lesion. 

Symptoms. — A  hard,  painless  cord,  un-      Symptoms. — A  cord  not  so  hard  nor  so 

accompanied  by  heat,  redness,  or  ten-         sharply  circumscribed  ;  often  painful, 

derness.    Erection  painless.    Little  or         especially   on   erection ;    tender   and 

no  oedema.  accompanied   by  heat,    redness,   and 

oedema  of  the  overlying  skin. 
Termination. — Undergoes  resolution  and       Termination. — Undergoes  suppuration  or 
is  uninfluenced  by  local  treatment.  resolution.     Local  treatment  effective. 

Syphilitic  Bubo.  Inflammatory  Bubo. 

Ckmse. — Always  chancre.  Cause. — Chancroid,   herpes,  balanopos- 

thitis,  gonorrhoea,  or  any  non-specific 
lesion. 
Number. — Several    glands,    usually    in      Number. — One  gland  implicated.  Rarely 

both  groins.  bilateral. 

Time  of  Appearance. — Shortly  after  chan-       Time    of    Appearance. — At     any    time 


ere 


about  one  week.  during  the  existence  of  a  lesion. 


848  GENITO-URINARY   DISEASES  AND   SYPHILIS. 

Symptoms. — Small,    indolent,    painless,  Symptoms. — A    large,    tender,    painful, 

movable,   non-inflammatory   tumors,  acutely  inflamed  tumor,  adherent  to 

non-adherent  to  the  skin,  and  of  car-  the   skin,  and  causing   redness    and 

tilaginous  hardness.  heat  of  the  latter.     The  hardness  is 

that  of  inflammation. 

Termination. — Resolution .  Termination. — Frequently  suppuration. 

Treatment. — Local      remedies      without  Treatment. — Local   treatment    curative  ; 

effect.     General  mercurial  treatment  general  mercurial  treatment  useless, 
hastens  resolution. 

The  diagnosis  of  syphilitic  buboes  from  the  lymphatic  enlargement 
so  frequently  noted  in  strumous  patients  must  depend  entirely  on  the 
history  of  the  case  and  the  development  of  the  tumors.  The  strumous 
adenomata  neither  increase  nor  decrease  in  size  unless  they  become 
inflamed,  in  which  case  they  break  down  and  suppurate.  A  tuber- 
cular family  history,  together  with  other  signs  of  struma  about  the 
patient,  can  often  be  ehcited ;  there  is  no  progressive  glandular  in- 
volvement first  of  the  lymphatics  anatomically  connected  with  the  seat 
of  the  sore,  then  of  all  the  lymphatics  accessible  to  the  examining 
fingers  ;  and  finally  resolution  does  not  partly  or  wholly  take  place  in 
the  majority  of  cases  in  from  two  to  six  weeks,  nor  is  this  resolution 
in  the  slightest  degree  cfuickened  by  the  administration  of  mercury. 

Treatment. — Syphilitic  infiltration  of  the  lymphatic  vessels  and 
glands  usually  requires  no  treatment,  subsiding  spontaneously  soon 
after  the  disappearance  of  the  induration  of  the  chancre,  though  the 
enlargement  of  the  lymphatic  glands  may  persist  for  five  or  six 
months,  or,  exceptionally,  for  many  years.  The  administration  of 
mercury,  when  the  diagnosis  has  become  so  certain  that  its  use  is 
justifiable,  causes  a  rapid  disappearance  of  the  specific  infiltrate.  In 
cases  complicated  by  acute  inflammation  and  suppuration  the  treat- 
ment is  the  same  as  that  appropriate  to  chancroidal  lymphangitis  and 
bubo. 

The  Period  of  Secondary  Incubation. — The  period  between 
the  appearance  of  chancre  and  the  development  of  secondary  lesions 
varies  from  two  weeks  to  three,  or  even  six,  months.  The  average 
time,  however,  is  forty-two  days.  The  primary  lesion  often  remains 
during  the  whole  of  this  period. 

The  disease,  so  far  as  constitutional  symptoms  are  concerned,  is 
apparently  quiescent.  In  reality  the  virus  is  becoming  disseminated 
through  the  entire  system,  first  manifesting  its  effect  upon  the  ac- 
cessible lymphatic  glands  not  anatomically  connected  with  the  pri- 
mary sore.  Enlargement  of  these  glands  usually  constitutes  the  first 
secondary  symptom,  and  is,  except  changes  in  the  blood,  the  earliest 
positive  sign  of  constitutional  syphilis. 


CHAPTER   XXIV. 

CONSTITUTIONAL  SYPHILIS. THE  SYPHILIDES. SYPHILIS  OF  ALIMENTARY  CANAL. 

Constitutional  syphilis  includes  the  period  of  secondary  symp- 
toms, the  intermediate  period,  and  the  period  of  tertiary  symptoms. 

The  period  of  secondary  symptoms  is  characterized  by  : — 1.  Alter- 
ations of  the  blood.  2.  General  lymphatic  enlargement.  3.  Moderate 
fever,  the  temperature  reaching  100°  to  101°  F.  in  the  evening;  often 
associated  with  malaise  and  anorexia.  4.  Muscular  and  articular 
pains,  about  the  chest,  back,  and  upper  extremities,  usually  moderate 
in  severity,  but  sometimes  very  severe.  5.  Alopecia,  involving  the 
hairy  surfaces  of  the  entire  body,  and  causing  ragged  and  irregular 
bald  spots  very  unlike  those  incident  to  the  ordinary  atrophy  of  hair- 
follicles.     6.  Eruptions  of  the  skin  and  the  mucous  membranes. 

Frequently  associated  with  these  manifestations  are  symptoms 
dependent  upon  involvement  of  the  eyes,  the  nervous  system,  the 
bones  and  periosteum,  the  testicle,  and  the  liver  and  other  glands. 

The  term  secondary  syphilis  has  been  applied  to  those  lesions 
which  appear  during  the  first  two  or  three  years  of  the  constitutional 
disease,  and  which  are  for  the  most  part  superficial  ;  yet  it  must  be 
remembered  that  secondary  symptoms  may  never  appear,  the  first 
manifestation  of  constitutional  involvement  occurring  after  one  or 
two  years  in  the  deeper  ulcerative  form  of  surface  lesions,  or  in  the 
more  serious  visceral  complications  which  characterize  tertiary  or 
late  syphilis.  When  such  deep  ulcerative  lesions  are  noted  during 
the  period  when  secondary  symptoms  should  appear, — that  is,  in 
the  first  few  months  of  the  attack, — the  disease  is  known  as  malig- 
nant syphilis.  Conversely,  during  the  period  when  tertiary  eruptions 
and  visceral  complications  ordinarily  appear,  and  when  such  lesions 
are  actually  present,  lesions  particularly  characteristic  of  secondary 
syphilis  may  develop,  such,  for  instance,  as  papules  of  the  skin  or 
mucous  patches  of  the  mouth,  or  at  the  height  of  a  characteristic 
secondary  eruption  a  tubercular  or  gummatous  tertiary  lesion  may 
develop.  Irregular  syphilis  is  a  term  applied  to  cases  thus  differing 
in  course  from  those  ordinarily  observed. 

It  will  be  remembered  that  the  diagnosis  of  syphilis  can  be  made 
with  absolute  surety  only  when  one  or  more  of  the  constitutional 
symptoms  develop.     One  of  the  first  of  these  symptoms,  and  the  one 

849 


850  GENITO-UKIlSrAEY  DISEASES   AND   SYPHILIS. 

upon  which  diagnosis  is  usually  founded,  is  enlargement  of  lymphatic 
glands  at  a  distance  from  the  chancre.  Unless  treatment  be  started 
at  once,  there  will  usually  develop  in  a  few  days  following  this  enlarge- 
ment the  secondary  symptoms  already  mentioned, — namely,  fever 
osteocopic  pains,  skin  eruptions,  mucous  patches,  sore  throat,  falling 
of  the  hair  in  patches,  and  at  times  iritis,  orchitis,  or  jaundice. 

Alteration  in  the  Blood.  Diagnosis. — If  systematic  observa- 
tions of  the  blood  be  made,  there  will  be  found  a  diminution  in  the 
hgemoglobin  percentage  and  red  corpuscles,  with  slight  leucocytosis. 
These  blood  changes  are  the  first  sign  of  constitutional  syphilis,  pre- 
ceding lymphatic  enlargement  by  two  or  three  weeks ;  they  become 
more  marked  with  the  advent  of  fever  and  on  the  appearance  of  the 
eruption. 

It  is  upon  alteration  of  the  blood  that  the  positive  diagnosis  of 
constitutional  syphilis  is  based.  In  the  blood  of  the  syphilitic  there  is  a 
specific  antibody,  the  presence  of  which  is  most  certainly  determined 
by  the  Wassermann  reaction.  In  applying  this  test  for  syphilis  there 
is  needed  an  antigen,  a  complement  and  ahsemolytic  system.  Antigen 
is  the  substance  which  when  introduced  into  living  tissues  excites  the 
production  of  another  substance  w^hich  neutralizes  the  antigen  and 
which  is  termed  antibody.  For  this  neutralization,  which  is  accom- 
plished by  a  process  of  union,  a  third  substance,  named  complement? 
is  necessary ;  the  complement  itself  being  neutralized  or  destroyed 
in  the  process  of  the  union  between  antigen  and  antibody.  The 
antigen  and  antibody  of  each  disease  are  apparently  specific  for  that 
disease.  Complement  is  not  specific,  and  is  found  in  all  fresh  blood 
sera.  The  Wassermann  reaction  has  for  its  end  the  detection  of  a 
syphilitic  antibody.  Extract  of  the  syphilitic  fetal  liver,  which  con- 
tains great  numbers  of  the  tryponemata,  is  used  as  an  antigen.  The 
hsemolytic  system  demonstrates  the  neutralization  of  the  complement 
by  the  addition  of  a  syphilitic  liver  extract  to  the  serum  of  a  syphilitic 
patient.  In  the  absence  of  the  specific  antibody,  t.e.,  when  the  serum 
to  be  tested  is  not  syphilitic,  complement  will  not  be  neutralized,  hence 
is  available  for  the  production  of  hsemolysis.  The  serum  to  be  tested 
is  obtained  by  aspiration  from  a  vein,  and  is  decomplimentized  by  heat 
(60°  C.) ;  the  syphilitic  antigen,  by  making  a  10  per  cent,  alcoholic 
extract  or  a  20  per  cent,  watery  extract  of  crushed  congenital  syphilitic 
liver.  The  washed,  plasma  free,  sheep's-blood  corpuscles  are  used 
as  the  hsemolytic  antigen.  The  hsemolytic  antibody  is  prepared  by 
injecting  a  rabbit  intravenously  with  washed  sheep's-blood  corpuscles. 
The  serum  obtained  from  tlie  rabbit's  blood  is  decomplementized. 
The  serum  of  guinea-pig's   blood   provides  the  complement.      The 


CONSTITUTIONAL  SYPHILIS.  851 

antigen  (syphilitic  liver  extract),  complement  (guinea-pig  serum.)  and 
test  serum  are  placed  in  a  tube  and  incubated  (37°  C).  Thereafter 
the  haemolytic  system,  i.e.,  the  haemolytic  antigen  and  antibody,  are 
added.  If  there  be  no  hasmolysis  it  is  evident  that  complement  has 
been  used  up  by  the  union  of  the  syphilitic  antigen  in  the  liver  extract 
with  a  specific  antibody  in  the  patient's  serum. 

As  to  the  accuracy  of  the  Wassermann  test,  all  untreated  congenital 
cases  give  positive  results.  During  the  first  fourteen  days  of  the  period 
of  primary  lesion  the  results  are  negative.  Thereafter  they  become 
more  frequently  positive  until  the  end  of  the  fourth  week,  when  about 
three  cases  out  of  four  give  the  positive  reaction.  Secondary  syphilis 
gives  positive  results  in  over  ninety  per  cent,  of  cases,  tertiary  syphilis 
in  about  seventy-five  per  cent.  General  paralysis  gives  the  reaction  in 
over  ninety  per  cent.;  tabes  in  more  than  fifty  per  cent. 

Syphilitic  women  giving  a  positive  reaction  may  bear  children  whose 
serum  shows  a  negative  one  ;  or  they  may  show  no  symptoms  yet  give 
a  positive  reaction.  When  a  number  of  results  taken  at  intervals  of 
three  to  six  months  are  negative,  the  infection  probably  has  been  erad- 
icated. Early  vigorous  treatment  causes  the  most  rapid  disappearance 
of  the  Wassermann  reaction,  both  in  the  secondary  and  tertiary  stage. 

Enlargement  of  Lymphatic  Glands  not  anatomically  con- 
nected "with  the  Chancre. — The  indolent  enlargement  which  prob- 
ably involves  to  some  extent  all  the  lymphatic  glands  of  the  economy, 
and  which  becomes  apparent  to  the  touch  in  certain  accessible  regions 
about  the  sixth  week  from  the  appearance  of  the  chancre,  must  not 
be  confounded  with  the  syphilitic  buboes  which  develop  in  about  a 
week  in  the  group  of  glands  anatomically  nearest  to  the  chancre.  This 
late  glandular  enlargement  when  characteristically  developed  is  pathog- 
nomonic of  syphilis.  While  probably  all  the  lymphatic  glands  are  in- 
volved, those  in  the  post-cervical  regions  and  the  epitrochlear  gland, 
lying  in  front  of  the  internal  condyle  of  the  humerus,  are  most  prone 
to  exhibit  the  indolent  cartilaginous,  painless,  non-inflammatory  en- 
largement so  characteristic  of  developing  secondary  syphilis.  The 
submaxillary,  the  anterior  cervical  group,  the  axillary,  in  fact,  all  the 
superficial  glands,  may  show  the  specific  induration,  but  rarely  in  so 
characteristic  a  manner  as  those  in  the  two  regions  named.  The 
tumors  formed  vary  from  the  size  of  a  pea  to  a  chestnut. 

The  post-cervical  chain  passing  downward  from  the  occipital  bone 
along  the  outer  edge  of  the  trapezius  muscle  is,  in  cleanly  people  at 
least,  rarely  enlarged  from  causes  other  than  syphilis  ;  thus  painless, 
hard,  indolent  infiltration  of  these  glands  would  be  far  stronger  evi- 
dence of  specific  disease  than  a  similar  condition  noted  in  the  sub- 


852  GENITO-UEINAKY  DISEASES   AND  SYPHILIS. 

maxillary  and  anterior  cervical  group,  which,  owing  to  the  presence 
of  catarrhal  and  inflammatory  affections  of  the  throat  from  which 
they  receive  lymph,  are  found  enlarged  in  perhaps  the  majority  of 
people.  For  a  similar  reason  characteristically  enlarged  epitrochlear 
glands — that  is,  those  above  and  in  front  of  the  internal  condyle — 
constitute  presumptive  evidence  of  syphilis. 

In  syphilitic  lymphatic  glands  the  follicles  of  the  delicate  reticu- 
lated tissues  are  hypertrophied,  and  give  rise  to  small  lobulated 
projections  upon  the  surface  when  the  capsule  is  removed.  The 
lymph-spaces  exhibit  a  cellular  infiltration,  and  the  fibrous  tissues 
separating  the  alveoli  are  thickened.  Frequently  these  glands  remain 
more  or  less  hypertrophied  not  only  during  the  period  of  secondary 
lesions,  but  also  long  after  the  syphilides  have  disappeared. 

Although  there  is  no  clearly  established  relation  between  the 
extent  of  glandular  lesion  and  the  severity  of  other  secondary  symp- 
toms of  syphilis,  early  and  well-marked  glandular  involvement  fre- 
quently has  been  noted  in  attacks  of  more  than  usual  severity. 

Syphilitic  Fever. — About  the  time  of  glandular  enlargement,  and 
coincident  with  the  earhest  eruption,  or  preceding  it,  fever  develops, 
associated  with  pallor,  weakness,  general  malaise,  headache,  coated 
tongue,  anorexia,  and  muscular  or  arthritic  pains.  The  temperature 
rarely  rises  above  102°  F.,  and  the  pulse  is  not  markedly  affected.  In 
many  patients  the  fever  is  either  absent  or  so  slightly  marked  that  it 
is  not  noticed.  It  rarely  becomes  so  severe  as  to  oblige  the  patient 
to  keep  to  his  bed.  Exceptionally  it  assumes  a  malarial  type,  being 
characterized  by  irregular  paroxysms  of  chills,  fever,  and  sweat,  but 
dififers  from  malaria  in  the  irregularity  of  the  paroxysms  and  in  the 
fact  that  quinine  is  utterly  without  effect  in  controlling  it,  while  mer- 
cury is  curative. 

When  the  fever  is  continued  and  moderate  in  severity,  and  asso- 
ciated with  depression  of  spirits,  pallor,  headache,  and  general  de- 
bility, it  may  strongly  suggest  typhoid.  If  continued  and  of  high 
grade,  running  to  104°  or  105°  F.  and  associated  with  evident  osteo- 
copic  pains,  it  may  lead  to  a  suspicion  of  developing  eruptive  fever. 
If  associated  with  an  outbreak  of  pustular  syphiloderm,  such  as  ex- 
ceptionally appears  as  an  early  skin  lesion,  the  diagnosis  from  small- 
pox may  be  exceedingly  difficult. 

The  involvement  of  the  joints  in  early  syphilis  maf,  if  associated 
with  syphilitic  fever,  make  the  diagnosis  of  the  latter  from  rheumatic 
fever  a  matter  of  impossibility  till  other  symptoms  of  syphilis  develop. 

Diagnosis. — In  making  a  diagnosis  of  syphilitic  fever,  the  history 
of  a  preceding  chancre  and  the  presence  of  general  lymphatic  enlarge- 


CONSTITUTIONAL   SYPHILIS.  853 

merits  are,  of  course,  matters  of  prime  importance.  In  addition  to  the 
history,  it  is  to  be  noted  that  syphilitic  fever  is  frequently  associated 
with  a  clean  tongue,  good  digestion,  normal  condition  of  the  bowels, 
and  an  absence  of  the  special  diagnostic  features  which  characterize 
each  of  the  fevers  with  which  it  may  be  confounded,  as,  for  instance, 
the  Plasmodia  and  enlarged  spleen  of  malaria,  the  tympany  and  spots 
of  typhoid,  the  crisis  of  variola,  the  drenching  sweats  and  acid  urine 
of  rheumatism. 

It  commonly  subsides  shortly  atter  the  appearance  of  the  erup- 
tion. When  it  is  continuous  in  type,  is  pronounced,  and  lasts  for 
some  time,  the  probability  is  that  the  attack  of  syphilis  will  be  un- 
usually severe  and  prolonged.  In  exceptional  cases  it  does  not  appear 
till  after  the  eruption  has  developed.  It  is  mostly  in  women  that  the 
severe  forms  of  continuous  syphilitic  fever  are  observed. 

Syphilitic  Neuralgia. — Coincidently  with  the  syphilitic  fever  and 
constituting  one  of  its  symptoms,  but  also  developing  in  the  absence 
of  evident  fever,  or  sometimes  preceding  it,  there  may  be  dull  pain, 
which  is  commonly  neuralgic  and  shifting  in  character,  and  is  felt 
mostly  about  the  back  of  the  neck,  the  back,  and  the  shoulders, 
though  it  may  be  localized  in  any  portion  of  the  fibro-osseous  sys- 
tem. This  pain  is  most  apt  to  be  noticed  at  night ;  when  continuous 
and  severe  there  are  usually  nocturnal  exacerbations.  It  occasionally 
attacks  one  or  more  joints,  and  may  be  accompanied  by  effusion  and 
fixation ;  or  it  may  assume  a  distinctly  neuralgic  type,  simulating 
pleurodynia  or  other  form  of  locahzed  pain.  Headaches,  with  noc- 
turnal exacerbations,  and  sometimes  associated  with  vertigo  and 
nausea,  point  to  meningeal  congestion. 

Frequently  the  pains  are  osteocopic  (bone-breaking)  in  character, 
and  are  accompanied  by  marked  tenderness  over  certain  bones,  par- 
ticularly the  middle  third  of  the  ribs  and  the  lower  third  of  the 
sternum.  This  is  so  often  noted  that  some  diagnostic  value  is  given 
to  the  presence  of  pain  on  moderate  pressure  over  these  bones. 
These  osteocopic  pains  are  explained  (Jullien)  on  the  ground  that 
the  medulla  of  the  bone  takes  part  in  the  general  lymphatic  enlarge- 
ment, thus  occasioning  pressure  upon  the  nerves.  Painful  nodular 
swellings  over  the  frontal  and  parietal  bones,  or  over  the  long  bones, 
are  also  noted  at  times. 

In  doubtful  cases  rheumatoid,  neuralgic,  and  osteocopic  pains, 
either  singly  or  associated,  are  of  great  value  in  deciding  for  or  against 
the  presence  of  syphilis.  In  some  instances  lymphatic  enlargement 
and  syphilitic  pains  may  be  the  only  symptoms  which  develop,  fever 
being  absent. 


354  GENIT0-I7EINAEY  DISEASES   AND   SYPHILIS. 

Among  the  symptoms  which  exceptionally  precede  alopecia  and 
the  secondary  eruption,  jaundice,  albuminuria,  ravenous  appetite  or 
bulimia,  alteration  in  the  sensibility  of  the  skin,  exaggerated  reflexes, 
and  enlargement  of  the  spleen  have  been  observed. 

Syphilitic  Eruptions  of  the  Skin  and  the  Mucous  Mem- 
branes.— The  syphilides,  or  eruptions  of  the  skin,  commonly  appear 
a  few  days  after  the  general  glandular  enlargement,  though  they  are 
occasionally  the  first  manifestations  of  constitutional  disease.  They 
are  usually  found  about  the  forty-second  day  after  the  chancre. 
Exceptionally  they  have  been  seen  within  two  weeks.  On  the  other 
hand,  they  may  not  develop  for  four  or  five  months,  or  in  some 
few  cases  secondary  syphihs  may  never  appear,  tertiary  lesions  first 
proving  conclusively  that  a  genital  sore  was  a  chancre.  This  is 
especially  liable  to  be  the  case  if  mercury  has  been  given  before  the 
appearance  of  secondary  symptoms. 

Cutaneous  and  mucous  syphilides  are  more  superficial  in  the 
early  stages  of  the  constitutional  disease ;  as  it  grows  older  these 
lesions  become  deeper. 

Thus  the  syphilides  of  the  first  period  of  secondary  syphilis  are 
due  to  a  local  hyperaemia  and  slight  cell-infiltrate,  affecting  only  the 
epidermic  and  papillary  layers  of  the  skin  and  producing  erythema- 
tous, macular,  and  papular  lesions.  These  heal  without  leaving 
scars.  The  older  syphiUdes  belonging  to  the  late  secondary  and  the 
tertiary  period  not  only  affect  the  epiderm  and  the  papillary  layer, 
but  involve  also  the  true  derm  and  even  the  subdermic  tissues,  appear- 
ing as  pustules  and  tubercles,  which  are  often  destructive  and  are  fol- 
lowed by  cicatrices.  These  lesions  are  due  to  a  cell-infiltrate  much 
like  that  of  granulation-tissue,  except  that  it  is  not  nearly  so  vascular. 

The  syphilides  may,  so  far  as  the  lesions  are  concerned,  mimic 
with  absolute  fidelity  many  of  the  well-known  skin  diseases ;  there 
are,  however,  certain  characteristics  of  the  eruption,  taken  as  a  whole, 
which  will  generally  make  a  correct  diagnosis  possible. 

The  general  features  of  secondary  syphilitic  eruptions  are  as 
follows : 

1.  The  lesions  develop  slowly,  are  painless,  and  do  not  itch. 

2.  They  are  rounded  in  form  and  grouping,  and  tend  to  scale. 

3.  They  are  of  a  copper  or  raw-ham  color. 

4.  They  are  symmetrical. 

5.  They  are  polymorphous. 

6.  They  are  superficial. 

7.  They  yield  to  mercurial  treatment. 

The  later  eruptions  of  the  secondary  period — that  is,  those  occur- 


CONSTITUTIONAL  SYPHILIS.  855 

ring  after  the  first  year — and  those  of  the  intermediarj-  and  tertiary 
periods  exhibit  the  following  characteristics  : 

1.  They  are  rounded  in  form  and  circinate  in  grouping.  This  is 
particularly  well  marked. 

2.  The  lesions  do  not  appear  as  a  general  eruption,  but  are  grouped 
upon  certain  regions  of  the  body. 

3.  They  are  deep,  often  involving  the  whole  thickness  of  the  skin 
and  the  subcutaneous  tissue.. 

4.  If  dry,  they  are  covered  with  a  thin  layer  of  gray,  slightly 
adherent  scales. 

5.  If  ulcerating,  they  form  punched-out,  chronic  ulcers,  often  cov- 
ered with  raised,  thick,  greenish-black,  adherent  crusts. 

6.  They  are  accompanied  by  very  slight  subjective  symptoms. 

When  a  general  eruption  first  appearing  on  the  chest  and  abdo- 
men presents  these  features  after  full  development,  it  can  certainly  be 
judged  syphilitic  in  its  nature.  Frequently,  however,  the  syphilide 
will  depart  in  one  or  more  points  from  the  type  to  which  it  should 
theoretically  correspond. 

The  absence  of  subjective  symptoms — that  is,  freedom  from  pain  and 
from  itching — is  a  rule  which  has  but  few  exceptions,  if  eruptions  on 
the  scalp  and  the  hairy  parts  of  the  body  are  excluded.  In  these 
regions  itching  is  very  common.  On  the  body  and  extremities  the 
eruption  is  often  not  noted  by  the  patient  till  the  physician  calls 
attention  to  it ;  or  the  patient  becomes  aware  of  it  only  because  he 
has  noticed  it  while  dressing  or  bathing. 

Exceptionally  the  itching  is  severe  and  harassing ;  this  may  arise 
from  the  specific  eruption,  but  commonly  it  is  found  to  be  dependent 
upon  an  intercurrent  condition,  such  as  urticaria  or  prurigo  or  the 
presence  of  pediculi. 

The  rounded  form  and  grouping  of  the  syphilides  are  usually  fairly 
well  marked,  though  individual  lesions  widely  depart  from  this  type. 
The  circinate  grouping  is  much  more  pronounced  in  the  late  sec- 
ondary and  in  the  tertiary  lesions ;  indeed,  it  is  a  striking  feature  of 
the  eruption.  In  the  early  secondary  lesions,  particularly  in  roseola, 
this  grouping  is  rarely  so  conspicuous  as  to  be  noticeable  till  it  is 
carefully  searched  for. 

The  raw-ham  or  copper  color  of  the  eruption  is  not  pronounced  at 
first.  The  early  erythema  is  usually  a  dusky  red,  though  it  may  pre- 
sent the  rosy-red  hue  of  simple  erythema.  As  the  lesions  develop, 
a  certain  amount  of  skin  pigmentation  takes  place,  the  erythe- 
matous patches  no  longer  disappearing  entirely  on  pressure,  but 
leaving  a  dark  stain.     The  macules  and  papules  become  still  more 


856  GBNITO-UKHSTAEY  DISEASES   AND  SYPHILIS. 

dusky,  like  raw  ham,  or  even  present  a  distinct  coppery  hue.  This 
is  fairly  constant,  but  is  not  characteristic  till  the  lesion  has  persisted 
at  least  some  days.  A  similar  coloration,  together  with  absence  of 
itching,  is  sometimes  observed  in  the  skin  eruptions  of  gouty  and 
rheumatic  subjects.  This  pigmentation  may  last  for  years ;  usually 
it  disappears  in  a  few  months.  The  epidermic  layer  of  the  skin 
suffers  by  reason  of  the  interference  with  its  nutrition  caused  by  the 
cell-exudation  in  the  papillary  layer  beneath  it.  Most  syphihdes, 
therefore,  tend  to  become  squamous. 

The  symmetrical  development  of  the  secondary  syphilides  is  an 
almost  constant  feature  of  the  eruption.  The  two  corresponding 
sides  of  the  body  are  usually  invaded  equally  and  by  a  somewhat 
similar  form  of  the  eruption.  This  tendency  to  symmetrical  develop- 
ment is  not  observable  in  tertiary  eruptions. 

The  polymorphism  of  secondary  syphilides  is  at  times  the  feature 
of  most  importance  in  establishing  a  correct  diagnosis.  This  term 
implies  that  the  lesion  is  many-formed ;  that  is,  while  in  one  part  of 
the  body  it  is  macular,  in  another  it  is  papular,  in  still  another  pus- 
tular, etc.  The  skin  diseases  which  syphilis  simulates  usually  con- 
form to  one  type ;  that  is,  if  certain  lesions  are  observed  in  one  part 
of  the  body,  similar  lesions,  and  no  others,  will  be  observed  in  other 
parts.     This  is  not  the  case  with  syphilis,  except  at  the  beginning. 

Usually  the  eruption  develops  gradually,  first  in  the  form  of  an 
erythema  so  slight  as  not  to  be  noticed  tih  the  patient's  skin  is  ex- 
posed to  the  air,  when  the  eruption  appears  on  the  anterior  and  lat- 
eral aspects  of  the  chest  and  belly  as  an  exaggeration  of  that  mottling 
which  constantly  occurs  when  a  portion  of  the  surface  generally  cov- 
ered is  suddenly  chilled.  This  erythema  becomes  quite  distinct  in  a 
few  days.  It  persists  and  gradually  shows  the  pigmentary  changes ; 
but  in  the  mean  time  papules  are  developing  in  certain  regions,  or 
perhaps  pustules  or  vesicles.  The  multiform  eruption  is  due  to  the 
fact  that  the  lesions  persist,  one  variety  not  completing  its  course 
before  another  is  developed. 

The  general  eruption  receives  its  name  from  the  predominant 
lesion. 

The  superficial  character  of  the  early  syphilides  is  due  to  the 
tendency  of  bacterial  growth  to  occur  in  regions  where  the  blood- 
current  is  slowed.  The  most  marked  effects  of  the  disease  in  this 
early  secondary  stage  are,  therefore,  shown  in  the  papillary  layer  of 
the  skin,  the  epidermis  becoming  secondarily  involved. 

The  Influence  of  Ilercurial  Treatment— Although  individual  lesions 
may  persist  for  months  in  spite  of  most  careful  medication,  the  usual 


CONSTITUTIONAL   SYPHILIS.  857 

effect  of  efficient  mercurial  treatment  upon  general  secondary  syphi- 
litic eruptions  is  prompt  and  pronounced.  Within  a  week  the  erup- 
tion is  undergoing  rapid  resolution.  This  gives  a  means  of  diagnosis 
which  in  doubtful  cases  is  exceedingly  valuable. 

Eruptions  of  the  Mucous  Membranes. — Involvement  of  the  mucous 
membrane  of  the  mouth  is  one  of  the  most  constant  symptoms  of 
constitutional  syphilis.  It  often  occurs  even  before  the  skin  erup- 
tions. 

It  may  appear  in  the  form  of  an  acute  erythema  (acute  syphilitic 
angina),  involving  the  palate,  half-arches,  tonsils,  and  pharynx,  accom- 
panied by  a  marked  oedema,  closely  resembhng  the  non-specific  sore 
throat,  and  generally  ascribed  to  catching  cold ;  more  commonly  it 
appears  in  the  form  of  mucous  patches.  Indeed,  these  are  the  most 
constant  lesions  of  secondary  syphilis.  They  are  commonly  found  on 
the  tongue,  the  buccal  mucous  membrane,  the  half-arches,  the  tonsils, 
and  the  palate.  Exceptionally  they  extend  from  the  posterior  half- 
arch  to  the  pharyngeal  mucous  membrane.  They  appear  as  gray- 
white,  irregularly  shaped  markings,  not  elevated  above  the  surround- 
ing healthy  surface.  The  appearance  presented  by  an  individual  lesion 
is  very  like  that  produced  by  brushing  the  mucous  membrane  with  a 
stick  of  silver  nitrate,  except  that  the  margins  of  the  mucous  patch 
are  more  sharply  defined. 

Together  with  the  mucous  patches  there  are  often  erosions  and 
fissures  of  the  tongue.  The  latter  when  deep  and  placed  at  the  sides 
of  the  organ  are  painful,  though  the  mouth  eruption  of  secondary 
syphilis  conforms  to  the  general  character  of  the  disease  in  presenting 
few  subjective  symptoms.  Contact  with  irritating  or  very  hot  foods 
may,  however,  cause  pain. 

Both  the  mucous  patch  and  acute  erythema  also  develop  in  the 
urethra  of  the  male,  giving  rise  to  a  discharge  which  may  simu- 
late a  mild  attack  of  gonorrhoea.  In  the  female  there  may  be  acute 
erythema  of  the  vagina;  more  commonly,  indeed,  in  the  majority  of 
cases,  mucous  patches  develop  about  the  vaginal  outlet. 

Syphilitic  Alopecia. — The  impaired  nutrition  of  the  hair-follicles 
incident  to  constitutional  syphilis  causes  the  hair  to  lose  its  lustre  and 
to  come  out  in  irregular  patches.  Usually  the  scalp  and  the  eye- 
brows are  alone  affected.  Sometimes  all  the  hairy  regions  are  in- 
volved, and  there  results  complete  denudation  of  the  entire  body. 

The  rapid  onset  of  the  baldness,  the  irregularity  of  distribution, 
and  the  fact  that  under  constitutional  treatment  it  is  completely 
curable  are  characteristic  features  of  the  condition. 

At  times  alopecia  attacks  the  eyebrows  alone,  causing  an  irregular 


858  GENITO-UEIKAKT   DISEASES  AND   SYPHILIS. 

bald  patch.  This  is  so  pecuhar  to  syphihs  that  it  is  considered  diag- 
nostic.    (Fournier.) 

The  alopecia  which  comes  on  later  in  the  disease  as  a  consequence 
of  ulcerative  lesions  is  due  to  atrophy  of  the  hair-folhcles,  and  is 
incurable. 

Syphilitic  onychia  is  dependent  upon  impaired  nutrition  of  the 
nail  matrix,  and  is  commonly  associated  with  the  papular  or  pus- 
tular eruptions.  The  nails  may  become  brittle  and  lustreless,  oi 
may  be  hypertrophied  and  deformed,  or  may  exfoliate.  These  pro- 
cesses are  associated  at  times  with  deep  ulceration  around  the  nails 
(perionychia). 

Syphilitic  Involvement  of  the  Viscera. — At  about  the  time 
the  early  constitutional  symptoms,  such  as  general  lymphatic  enlarge- 
ment, fever,  and  syphilodermata,  develop,  there  may  be  manifestations 
of  the  disturbing  effect  of  the  virus  upon  the  viscera,  though  such 
signs,  at  least  in  their  more  serious  forms,  do  not  usually  occur  till 
late  in  the  disease.  The  visceral  symptoms  which  develop  in  early 
secondary  syphihs  are  nearly  always  dependent  upon  an  acute  hyper- 
aemia  which,  though  caused  by  the  syphilitic  poison,  differs  in  no  way 
from  similar  conditions  brought  about  by  other  causes,  except  in  the 
fact  that  it  yields  promptly  to  specific  treatment.  Thus  there  may  be 
temporary  albuminuria  from  hypersemia  or  inflammation  of  the  kidney, 
violent  cephalalgia  from  meningitis,  pleural  effusion  from  pleuritis. 

In  the  early  stage  of  secondary  syphilis  the  liver  may  be  hyper- 
trophied. This  may  be  accompanied  either  by  pain  or  by  jaundice, 
or  by  both  of  these  symptoms.  Jaundice  does  not  appear  as  an 
isolated  symptom  of  syphilis.  Syphihdes  of  the  skin  or  of  the 
mucous  membrane  are  found  associated  with  it. 

It  is  more  convenient  to  consider  under  tertiary  syphilis  the  effects 
of  the  disease  on  the  muscles,  the  bones,  the  nervous  and  vascular 
systems,  and  the  viscera,  since  the  secondary  manifestations  of  the 
disease  in  these  portions  of  the  body  are  transitory  and  compara- 
tively rare,  and  present  only  the  ordinary  symptoms  of  a  more  or 
less  acute  inflammation. 

It  is  noteworthy  that  the  symptoms  in  connection  with  the  viscera 
become  less  acute  in  type  as  the  attack  of  syphihs  becomes  older,  and 
that  when  they  develop  they  resemble  the  chronic  rather  than  the 
acute  form  of  inflammation,  until  finally  in  the  tertiary  period  the 
formation  of  gummata  takes  place. 

Syphihtic  Disturbances  of  the  Nervous  System. — The 
commonest  symptom  of  involvement  of  the  nervous  system  in  con- 
stitutional syphilis  is  the  syphilitic  neuralgia,  to  which  reference  has 


CONSTITUTIONAL  SYPHILIS.  859 

already  been  made.  This  and  the  other  symptoms  may  be  dependent 
upon  the  general  cachexia,  or  more  rarely  may  be  due  to  pressure,  as 
from  enlarged  lymphatics  or  swelling  of  the  medulla  or  the  perios- 
teum of  bones.  The  first  and  second  branches  of  the  trifacial  nerve 
are  especially  subject  to  this  form  of  syphilitic  neuralgia. 

Cephalalgia  is  common  in  the  early  secondary  period.  It  is  usu- 
ally of  moderate  severity,  is  not  a  surface  pain,  but  is  located  in  the 
frontal  or  the  occipital  region  of  the  brain,  and  is  harassing  rather 
than  disabling ;  there  are  nocturnal  exacerbations.  Very  excep- 
tionally it  becomes  exceedingly  severe. 

Analgesia  when  present  is  found  over  the  metacarpal  region  of 
each  hand.  It  is  an  early,  usually  symmetrical  lesion,  and  is  not  ac- 
companied by  anaesthesia,  tactile  sensation  being  retained.  It  may 
exceptionally  take  the  form  of  thermo-analgesia  or  muscular  analgesia. 

Paralysis,  particularly  of  the  muscles  of  the  eye  and  the  face,  is 
occasionally  observed  in  early  syphilis.  It  may  involve  single  muscles 
or  muscle  groups,  or  may  cause  hemiplegia  or  paraplegia. 

The  nerve  manifestations  of  secondary  syphihs  are  usually  short- 
lived and  yield  quickly  to  constitutional  treatment. 

Syphilitic  involvement  of  the  bones,  joints,  and  tendinous 
sheaths  is  not  rare  in  the  secondary  stage  of  the  disease.  The  bones 
lying  nearest  the  surface  exhibit  painful  nodular  swellings  with  the 
characteristic  symptoms  of  acute  periostitis.  One  or  many  joints  may 
be  the  seat  of  more  or  less  acute  inflammation.  Certain  of  the  ten- 
dinous sheaths  may  develop  the  crackhng  and  tenderness  of  teno- 
synovitis. 

Iritis  is  the  commonest  eye  manifestation  of  secondary  syphilis ; 
it  may  assume  the  plastic  or  the  serous  form.  In  either  case  the 
symptoms  are  like  those  of  the  inflammatory  form  of  the  disease, 
except  that  they  are  less  acute. 

Epididymitis  occasionally  develops  as  a  lesion  of  early  constitu- 
tional disease  ;  it  is  unilateral,  painless,  and  quickly  subsides  on 
treatment.     Orchitis  is  rarely  observed  till  the  tertiary  stage. 

As  a  result  of  secondary  syphilis,  menstrual  disturbances  are  very 
common :  these  may  take  any  of  the  forms  noted  in  debility  from 
other  causes.  Both  amenorrhoea  and  metrorrhagia  have  been  ob- 
served.    In  the  pregnant  uterus  abortion  generally  occurs. 

SYPHILITIC   SKIN  ERUPTIONS. 

It  should  be  remembered  that  recent  syphilides  (secondary)  are 
superficial,  while  later  eruptions  (tertiary)  are  deep,  but  that  typical 
tertiary  eruptions  may  exceptionally  appear  in  the  secondary  stage 


860  GENITO-UKINARY   DISEASES  AND  SYPHILIS. 

of  the  disease,  or  the  secondary  eruptions  may  appear  late.     The 
skin  lesions  of  syphilis  may  be  classed  as  follows : 

1.  Erythematous  syphilides,  called  also  erythema,  macules,  roseola. 

2.  Papular  syphilides.  In  accordance  with  their  size,  shape,  and 
surface,  the  papular  syphilides  are  : 

A.  Conical  or  acuminated  papular  syphilides. 

a.  Large. 

b.  Small. 

B.  Flat  or  lenticular  papular  syphilides. 

a.  Large. 

b.  Small. 

C.  Moist  papules  (mucous  patches). 
I).  Papulo-squamous  syphihdes. 

3.  Vesicular  Syphilides. 

4.  Pustular  syphilides. 

a.  Small,  acuminated  pustular  syphilides  (miliary). 
6.  Large,  acuminated  pustular  syphilides  (acneiform). 
e.  Small,  flat  pustular  syphihdes  (impetiginous). 
cl  Large,  flat  pustular  syphilides  (ecthymatous). 

5.  Pigmentary  syphihdes. 

6.  Buhous  syphihdes. 

7.  Tubercular  syphilides. 

8.  Gummatous  syphilides. 

A  pathological  study  of  the  secondary  skin  eruptions  shows  that 
they  are  made  up  of  a  small  round-celled  infiltration  of  the  cutis  and 
adnexa,  together  with  the  lower  layers  of  the  rete  Malpighii.  The 
blood-vessels  are  dilated,  the  endothelium  is  thickened,  and  there  is  a 
small-celled  infiltrate  of  the  adventitia.  These  changes  involve  the 
vessels  of  the  papillae,  the  Malpighian  net-work,  the  hair-folhcles,  the 
sebaceous  glands,  and  the  sweat-glands.  Whether  the  eruption  be 
macular,  papular,  or  pustular,  the  pathology  is  the  same. 

The  pathology  of  the  tertiary  lesions  differs  from  that  of  the 
secondary  only  in  that  the  small-celled  infiltrate  is  much  more  exten- 
sive, invading  the  entire  thickness  of  the  skin  and  the  subcutaneous 
tissues.  As  a  result,  this  mass  of  embryonal  tissue,  always  poorly 
vascularized,  degenerates  centrally,  and  either  ulcerates,  discharging 
externally,  or  is  partly  absorbed  and  partly  converted  into  fibrous 
tissue. 

Grouping  the  skin  lesions  in  accordance  with  the  time  of  develop- 
ment, the  eruptions  of  the  secondary  period  are : 

The  erythematous  syphilides  (roseola) ;  the  papular  and  papulo- 
squamous  syphilides  (mucous   patch,  lichen,   condyloma,  psoriasis. 


Fig.  264. 


Krythematous  syphilide. 
(From  the  colleotion  of  photographs  of  Dr.  George  Henry  Fox.) 


CONSTITUTIONAL   SYPHILIS.  861 

etc.) ;  the  general  pustular  syphilides  (acne,  impetigo) ;  the  pigmentary 
syphilides ;  the  bullous  syphilides ;  the  vesicular  syphilides  ;  the  tuber- 
cular syphilides. 

During  the  same  time  there  may  develop  on  the  mucous  mem- 
branes : 

1.  An  acute  erythema; 

2.  Mucous  and  scaly  patches  ;  or, 

3.  Superficial  ulcerations. 

With  the  exception  of  the  pigmentary  syphilide  and  the  squamous 
form  of  the  papular  syphilide,  these  are  general  eruptions  and  appear 
during  secondary  syphilis  in  about  the  order  given,  the  tubercular 
lesion  being  well  on  the  border-line  between  the  secondary  and  the 
tertiary  period. 

The  syphilides  of  the  tertiary  stage  are  pustular  and  bullous 
syphilides,  which  appear  discretely  or  in  groups,  and  which  ulcerate 
deeply  (ecthyma,  rupia),  and  gummata. 

The  mucous  membrane  manifestations  of  this  stage  are  mucous 
and  scaly  patches  and  gummata. 

Erythematous  Syphilide. — This  is  the  earliest  and  the  most 
constant  of  all  the  skin  lesions  of  syphilis.  It  appears  about  the  same 
time  that  the  general  lymphatic  enlargements  become  apparent.  In 
the  uncleanly  and  careless  it  may  run  its  course  without  attracting  the 
attention  of  the  patient.  The  eruption  exhibits  less  of  the  rounded 
shape  or  grouping  than  any  of  the  other  syphilides. 

It  first  appears  as  an  irregular  rose-red  mottling  of  the  surface, 
such  as  is  constantly  seen  when  covered  surfaces  are  exposed  to  the 
cold.  The  lesion  may  not  develop  beyond  this  point,  terminating 
promptly  under  treatment,  or  at  times  even  without  it,  in  a  slight 
branny  epithelial  shedding.  More  commonly  syphilitic  roseola  de- 
velops,— that  is,  patches  of  varying  size  are  formed,  the  smallest  not 
larger  than  a  pin-head,  the  largest  the  size  of  a  quarter-  or  a  half- 
dollar.  (P'ig.  264.)  These  patches  are  irregular  in  shape,  frequently 
rounded  or  oval,  but  not  necessarily  so,  and  shortly  become  raw- 
ham  or  even  coppery  in  color.  At  first  pressure  of  the  finger  and 
emptying  of  the  superficial  vessels  leave  the  skin  white  for  a  moment, 
but  later  there  is  distinct  pigmentation,  the  copper  color  remaining. 

The  eruption  commonly  appears  on  the  sides  and  front  of  the 
belly  and  chest.  It  is  also  frequently  observed  on  the  back  and  on 
the  flexor  surfaces  of  the  extremities.  It  is  sometimes  seen  at  the 
hair-line  of  the  forehead  and  upon  the  palmar  and  plantar  surfaces. 
It  may,  of  course,  develop  on  any  surface  of  the  body,  but  the  regions 
just  given  are,  in  their  order,  those  of  preference. 


862  GENITO-TJKINAET   DISEASES   AND   SYPHILIS, 

The  full  erythematous  eruption  develops  in  about  a  week.  Under 
treatment  it  rapidly  disappears,  even  the  pigment  being  absorbed  and 
leaving  no  trace.  If  not  treated,  it  lasts  for  weeks  or  months,  and  is 
accompanied  by  papular  and  pustular  lesions,  giving  the  eruption  one 
of  its  characteristic  features, — polymorphism. 

Diagnosis. — The  diagnosis  of  the  erythematous  syphilide  is  much 
simpMfied  by  the  presence  of  concomitant  signs  of  the  disease.  At 
this  stage  the  remains  of  a  chancre  are  usually  present,  the  enlarged 
glands  can  be  felt,  and  a  history  of  rheumatoid  pains,  of  sore  throat,  of 
headache,  and  of  a  slight  feverish  attack  will  be  given. 

Simple  erythema  and  the  copaiba  rash  may  both  simulate  syphi- 
litic roseola.  Simple  erythema,  however,  is  not  associated  with  a 
history  of  chancre  or  with  the  signs  of  early  secondary  syphihs,  is 
more  commonly  accompanied  by  distinct  fever  and  digestive  disorder, 
itches,  and  develops  and  subsides  in  a  short  time,  showing  no 
tendency  to  persist  and  to  become  pigmented. 

The  copaiba  rash  often  exhibits  large  itching  confluent  patches, 
which  run  their  course  in  a  few  days,  which  appear  with  special  in- 
tensity in  certain  regions,  such  as  the  extensor  surfaces  of  the  joints, 
and  which  subside  promptly  on  stopping  the  drug.  There  is  a  history 
of  ingestion  of  copaiba,  or,  if  this  is  denied,  an  examination  of  the 
urine  will  demonstrate  the  copaiba  odor. 

Measles  is  characterized  by  a  history  of  exposure  to  the  disease, 
Koplik's  spots,  high  fever,  cough,  an  eruption  beginning  on  the  face, 
and  becoming  universal  rapidly,  and  the  pinkish-red,  blotchy  appear- 
ance of  the  macules. 

Papular  Syphilide. — The  lesions  of  the  papular  syphiloderms 
appear  as  hard,  small  or  large,  acuminated  or  flat,  smooth  or  scahng, 
rounded  elevations,  exhibiting  a  characteristic  raw-ham  or  copper 
color.  These  lesions  are  due  to  circumscribed  hypersemia,  together 
with  cellular  infiltration  of  the  papillary  layer  of  the  skin.  They  are 
frequently  converted  into  vesicles  or  pustules. 

The  Small  Papular  Syphilide. — This  eruption  is  usually  an  early 
manifestation  of  constitutional  syphihs,  exceptionally  even  preceding 
the  roseola  ;  frequently  it  does  not  develop  till  considerably  after  the 
fourth  month.  The  papules  may  be  conical,  rounded,  flat  (lenticular), 
or  umbilicated,  and  often  exhibit  a  fine  scaling.  They  vary  in  size 
from  that  of  a  pin-head  to  that  of  a  split  pea.  At  first  rose-red,  they 
become  raw-ham  or  coppery  in  color.  The  lesions  are  apt  to  ex- 
hibit a  circinate  grouping,  appearing  as  segments  of  circles,  as  com- 
plete circles,  or  in  figures  of  eight.  The  eruption  is  usually  well 
marked  and  involves  a  large  surface.     (Fig.  265.) 


Fig.  265. 


Flat  papular  syphilide. 


Fig.  266. 


Acuminated  papular  sypliilide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


Fig.  267. 


Acuminated  papular  syphilide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


Fig.  270. 


»  <- 


Lar^e  flat  papular  syphilide. 
Fig.  271. 


Vegetations  and  mucous  patches  about  the  vulva. 


Fig.  272. 


Large  flat  papular  svphilide,  showing  scaling. 


CONSTITUTIONAL   SYPHILIS. 


863 


The  acuminated  (miliary)  form  is  first  noticed  on  the  face.  It  sub- 
sequently appears  on  the  trunk  and  the  extremities. 

The  flat,  lenticular,  Kchen-like  form  appears  first  about  the 
shoulders,  but  the  fape,  body,  and  extremities  are  soon  involved,  the 
lesions     being    ,  particularly 

abundant  about  the  flexures  ^'^'-  ^''^^ 

of  the  joints.  The  palmar 
and  plantar  surfaces  also 
suffer.  The  eruption  is 
somewhat  chronic  in  itf 
course,  and  is  more  resist- 
ant to  treatment  than  the 
erythema.  It  yields  in  three 
or  four  weeks,  but  is  sub- 
ject to  relapses. 

The  Large  Papular  Syph- 
iLiDE. — As  in  the  smaller 
lesions,  these  papules  may 
be  conical  or  flat. 

The  large  conical  pap- 
ules are  usually  discrete,  few 
in  number,  are  found  asso- 
ciated with  the  small  pap- 
ules, and  are  most  abundant  on  the  back,  the  buttocks,  the  back  of 
the  neck,  the  face,  and  the  extensor  surface  of  the  thighs.  (Figs.  266, 
267.) 

The  large,  flat  papules  vary 
in  size  from  that  of  a  shirt- 
button  to  that  of  a  penny. 
(Figs.  268,  269,  270.)  They 
are  sharply  circumscribed,  ele- 
vated, and  commonly  exhibit  a 
branny  scaling.  The  eruption 
may  be  widely  distributed  or 
may  be  grouped  in  certain  re- 
gions. Thus,  the  lesions  are 
frequently  found  on  the  back, 
the  nape  of  the  neck,  the  fore- 
head, the  flexor  surfaces  of  the 
extremities,  and  the  scrotum, 
and  about  the  mucous  outlets.  (Fig.  272.)  Sometimes  the  lesions 
become  fissured,  and  may  give  rise  to  severe  pain.     This  is  especially 


Mucous  patches  of  the  lips. 


Fig.  274. 


Mucous  patches  about  the  anus. 


864 


GENITO-UEINAEY   DISEASES   AND  SYPHILIS. 


apt  to  occur  on  the  hands  and  feet  and  about  the  mouth  and  the 
anus. 

Mucous  Patch. — When  the  papular  syphilide  develops  on  surfaces 
of  the  body  which  are  kept  constantly  moist  by  secretions,  or  which 
are  subject  to  moisture  and  friction,  as  on  mucous  surfaces  at  the 
angles  of  the  mouth  (Fig.  273),  beneath  the  dependent  mammary 
gland,  about  the  anus  (Fig.  274)  and  the  vulva  (Fig.  271),  Hvithin  the 
foreskin,  on  the  scrotum,  or  between  the  toes,  instead  of  the  branny 
scaling  which  characterizes  the  dry  lesion  there  is  often  an  abraded 
surface,  which  secretes  freely  and  is  partly  or  completely  covered  by  a 
gray,  adherent,  offensive  pseudo-membrane.  The  irritating  secretions 
of  these  mucous  patches  frequently  give  rise  to  warty  growths  in  the 


Fig.  275, 


Papular  f^yphilide,  showing  papillary  overgrowth. 

immechate  environment.  Sometimes  the  moist  papule  exhibits,  in 
addition  to  hyperaemia,  cell  infiltration  and  abrasion,  or  superficial 
ulceration,  a  distinct  papillary  overgrowth,  forming  small  or  large 
papillomata.     (Fig.  275.)    These  are  properly  termed  condylomata, 


COiSrSTITUTIONAL   SYPHILIS. 


865 


and  should  be  distinguished  from  the  mucous  patch  in  which  hyper- 
trophy of  the  papiUge  either  is  not  present  or  is  not  marked.  Com- 
monly these  condylomata  appear  as  raised  flat,  raw  surfaces,  the  cel- 
lular infdtration  being  so  abundant  that  the  papillary  nature  of  the 
growth  is  but  hnperfectly  marked.  Occasionally  large  cauliflower- 
like warty  growths  are  formed,  particularly  in  the  regions  of  the  face, 
scalp,  shoulders,  and  genitals  (Duhring).     These  are  termed  vegetating 

Fig.  276. 


Syphilitic  vegetations. 


papules,  and  are  often  accompanied  by  abrasions  and  crusting  of  the 
surrounding  skin.     (Fig.  276.) 

When  subject  to  friction  and  not  treated,  the  mucous  patches  may 
form  ulcers.  On  the  delicate  skin  of  babies  mucous  patches  fre- 
quently develop,  and  are  in  them  one  of  the  commonest  lesions  of 
syphilis.  In  the  adult  they  appear  early,  but  are  prone  to  relapses, 
and  may  occur  in  the  mouth  even  during  the  tertiary  stage  of  syphilis. 
The  secretions  of  the  mucous  patch  are  highly  contagious. 

Diagnosis  of  the  Papular  SyphUides. — The  concomitant  signs  of 
syphilis,  such  as  the  remains  of  a  chancre,  enlarged  lymphatic  glands, 
sore  throat,  alopecia,  scabs  in  the  hair,  etc.,  are  usually  present,  and, 


866  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

in  conjunction  with  the  copper  color  of  the  eruption,  its  polymor- 
phism, the  absence  of  itching,  and  its  grouping  about  the  back,  the 
neck,  the  forehead,  the  sides,  and  the  buttocks,  render  the  diagnosis 
of  this  syphilide  easy. 

When  the  large,  flat,  papular  syphilides  develop,  either  in  the 
dry  form  or  as  mucous  patches,  the  diagnosis  can  be  made  with  cer- 
tainty, since  these  lesions  are  absolutely  characteristic  of  syphilis  and 
are  simulated  by  no  skin  disease. 

Acne  papulosum  and  lichen  are  both  closely  simulated  by  some 
forms  of  the  papular  syphilides. 

Acne  papulosum  is  associated  with  none  of  the  concomitant  signs 
of  syphilis,  is  found  commonly  about  the  forehead,  cheeks,  chin, 
shoulders,  and  back,  leaves  no  pigmentation  at  the  seat  of  cured 
lesions,  and  is  often  accompanied  by  pustules  ;  or  there  may  be  scars 
resulting  from  the  healing  of  the  latter.  When  papular  acne  develops 
only  on  the  forehead,  the  diagnosis  must  be  formed  mainly  on  the 
absence  of  other  signs  of  syphilis. 

Lichen  may  be  acuminated  or  flat,  and  may  be  widely  distributed.' 
The  lesions  of  this  disease  are  dusky  in  color  and  occasion  pigmenta- 
tion of  the  skin.  The  individual  papules  are,  however,  angular  in 
outline  rather  than  rounded,  and  in  place  of  a  circular  grouping  are 
often  arranged  in  rows  or  lines.  They  usually  itch,  and  are  not 
associated  with  any  of  the  signs  of  syphilis.  The  eruption,  however 
diffuse  it  may  be,  is  papular  throughout. 

Keratosis  pilaris,  the  conical  elevations  seated  about  the  apertures 
of  the  hair-follicles  and  mostly  found  on  the  extensor  surfaces  of  the 
thighs  and  arms  and  on  the  forearms,  is  sometimes  mistaken  for  the 
small  miliary  syphilide.  The  absence  of  circular  grouping,  the  dis- 
tribution of  the  lesion,  the  uniform  appearance  presented  by  it,  and 
the  fact  that  each  papule  is  invariably  placed  at  the  aperture  of  a  hair- 
follicle,  will,  in  the  absence  of  other  signs  of  syphilis;  render  diagnosis 
easy. 

Prognosis. — Papular  syphilides  yield  to  treatment,  leaving  a  brown- 
ish pigmentation,  which  ultimately  disappears.  The  effect  of  mercury 
is  not  so  immediate  as  in  the  case  of  roseola.  Still,  in  a  few  weeks  a 
general  papular  eruption  usually  fades  completely  under  constitutional 
treatment.  The  recurrent  forms  are  somewhat  more  obstinate.  These 
are  prone  to  appear  in  circinate  groups. 

Treatment.—Mevduvy  should  always  be  given,  in  some  cases  pref- 
erably by  fumigation  or  inunction. 

Papulo-Squamous  Syphiudes. — There  is  more  or  less  desquamation 
with  all  the  papular  syphilides,  but  in  some  cases  this  may  be  so 


Fig.  277. 


Pai)ul()-s(niaiiioiis  syiiiiilide. 
(Prom  the  coUectiou  of  photographs  of  Dr.  George  Heury  Fox.) 


CONSTITUTIONAL   SYPHILIS. 


867 


marked  as  to  give  the  disease  a  distinctly  squamous  type.    The  lesions 
in  this  form  of  syphiloderm  are  generally  flat,  and  are  covered  with 

Fig.  278. 


Papulo-squamous  syphilide. 

fme   gray  scales,   which   are   not  very  tightly  adherent.     As   these 
scales  are  brushed  away,  the  coppery  glistening  surface  of  the  papule 

Fig.  279. 


Papulo-squamous  syjjhilide. 
(From  the  collection  of  photograplis  of  Dr.  George  Henry  Fox.) 

is  exposed,  surrounded  with  a  fairly  well-marked  collar  of  ragged 
epithelium. 


868 


GENITO-URINARY   DISEASES   AND   SYPHILIS. 


These  lesions  when  they  appear  early  may  be  multiple  and  gen- 
eral, the  patches  varying  in  size  as  do  those  of  papular  syphilis. 
(Figs.  277,  278.) 

In  recurrent,  late  eruptions  the  lesions  may  be  few  and  grouped. 
(Fig.  279.)  They  may  remain  weeks  or  months  without  increasing 
in  size,  and  commonly  exhibit  a  distinct  circinate  arrangement  of  the 
individual  papules  of  a  group. 

The  well-marked  papulo-squamous  syphihdes  usually  appear 
after  the  sixth  month,  and  may  develop  in  any  subsecpent  period  of 
the  disease.  The  distribution  of  this  lesion  is  similar  to  that  of  the 
papular  syphilide. 

On  the  palms  and  soles  these  papulo-squamous  eruptions  are  most 
frequent  and  most  resistant.     (Figs.  280,  281,  282,  283.)     In  the  early 


Fig.  280. 


Papulosquamous  syphilide  of  the  hand. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


period  of  the  disease  they  are  symmetrical ;  later  this  feature  is  not 
noted.  Instead  of  the  familiar  macule  with  glistening  coppery  centre 
and  gray  epithelial  scales  about  the  edges  there  may  be  a  marked 
overgrowth  of  the  corneous  layer  of  the  skin,  forming  hard  conical 
projections  in  size  from  that  of  a  pin-head  to  that  of  a  pea.  These 
can  be  dug  out  from  the  skin,  leaving  deep  pits  or  depressions.  They 
are  most  frequently  noted  on  the  soles,  and  are  liable  to  occasion 
pain  on  walking.  The  papulo-squamous  syphilides  of  the  palms  and 
soles  are  often  compMcated  by  painful  and  obstinate  fissures. 

These  lesions  may  appear  in  the  third  month,  or  much  later. 
They  are  prone  to  relapse,  beginning  about  the  centre  of  the  palm 
and  extending  peripherally,  forming  lesions  of  circinate  or  serpiginous 
shape. 

Papulo-squamous  eruption  of  the  palms  or  soles  alone,  accom- 


Fig.  281. 


Papulosquamous  syphilide  of  the  hand.    (Fox.) 


CONSTITUTIONAL  SYPHILIS.  869 

panied  by  but  slight  subjective  symptoms,  is  almost  pathognomonic 
of  syphilis.  Exceptionally  the  palmar  syphilide  appears  as  a  dif- 
fuse exfoliation  of  fine  epithelial  scales,  giving  the  surface  a  silvery 
aspect. 

Diagnosis. — Papulo-squamous  syphilides  must  be  distinguished 
from  psoriasis  and  from  palmar  eczema. 

Psoriasis  is  entirely  superficial,  exhibiting  but  slight  thickening,  is 
not  polymorphous,  frequently  appears  before  the  twentieth  year,  its 
individual  lesions  are  not  markedly  raised  above  the  level  of  the  sur- 
rounding surface,  it  is  covered  with  a  thick,  imbricated  skin,  made  up 
of  white  scales,  is  generally  symmetrical  (the  late  syphilitic  papulo- 
squamous eruption  does  not  usually  exhibit  this  feature),  is  rarely 
confined  to  the  palms  and  the  soles,  being  commonly  associated  with 
similar  lesions  grouped  about  the  extensor  surfaces  of  the  knees  and 
the  elbows,  is  always  dry,  is  extremely  chronic,  is  subject  to  relapses 
and  obstinate  to  treatment,  is  not  influenced  by  mercury,  and  pri- 
marily is  not  associated  with  other  signs  or  symptoms  of  syphilis. 

Eczema  of  the  palms  is  attended  with  discharge,  crusting,  and  itch- 
ing ;  it  begins  about  the  wrist  first,  and  not  in  the  centre  of  the  palm, 
and  is  not  as  sharply  outlined  as  the  specific  lesion.  When  jDalmar 
or  plantar  syphilides  become  fissured  or  eroded  they  cannot  be  dis- 
tinguished from  eczema.  Their  reaction  to  specific  treatment  is  so 
slow  that  the  therapeutic  test  is  of  little  service. 

The  circinate  form  of  papulo-squamous  syphiloderm  may  closely 
resemble  the  lesion  of  tinea  circinata ;  the  latter  is,  however,  pro- 
gressive, and  microscopic  examination  shows  the  parasite. 

Prognosis. — The  lesions  are  obstinate,  but  ultimately  heal ;  they 
may  leave  permanent  scarring.     Their  pigmentation  disappears. 

Treatment. — Mercury  and  potassium  iodide. 

Vesicular  Syphilide. — This  eruption  is  exceedingly  rare.  It 
may  closely  simulate,  so  far  as  the  skin  lesions  are  concerned,  almost 
any  of  the  non-specific  vesicular  diseases.  Thus  there  are  the  ecze- 
matous  form,  the  varicelloid  form,  and  the  herpetic  form. 

The  vesicles  may  be  small  or  large,  may  be  generafized,  or  may 
come  out  in  groups  in  certain  regions  of  the  body.  They  are  prone 
to  appear  about  the  hair-follicles.  They  are  observed  on  the  face, 
the  trunk,  and  the  extremities.  If  there  are  seats  of  preference,  these 
are  perhaps  the  face,  genitalia,  forearms,  and  legs. 

The  eczematous  form  appears  as  a  general  eruption  of  small 
vesicles,  either  discrete  or  in  patches,  and  generally  sparing  the  face. 
When  the  vesicles  are  discrete,  each  is  surrounded  by  a  characteristic 
raw-ham-colored  areola.     If  the  fluid  of  the  vesicles  remains  clear,  it 


870  GENITO-UKINARY    DISEASES   AND   SYPHILIS. 

may  break  through  its  thin  epidermic  wall  and  escape,  or  may  be  re- 
absorbed, leaving  only  a  slight  epidermic  exfoliation  and  temporary 
pigmentation ;  frequently,  however,  pustulation  takes  place,  and  thin 
yellow  crusts  are  formed  (impetigo).  This  last  form  is  prone  to 
appear  on  the  face  and  about  the  genitalia,  and  is  usually  associated 
with  papular  and  pustular  lesions  on  other  parts  of  the  body. 

The  diagnosis  from  vesicular  eczema  will  be  made  by  the  char- 
acteristic areola,  the  absence  of  itching  and  of  acute  inflammatory 
signs,  the  influence  of  mercury,  and  the  presence  of  associated  signs 
of  syphilis. 

The  varicelloid  form  appears  as  large,  not  very  numerous,  dis- 
crete, split-pea-sized  vesicles,  either  globular  or  umbihcated,  which 
persist  for  some  time,  and  then  rupture,  leaving  an  area  of  slight 
crusting  and  pigmentation.  Or  they  may  pustulate  (presenting  the 
appearance  of  varioloid)  and  crust.  The  base  of  each  vesicle  is  sur- 
rounded by  a  characteristic  copper-colored  areola,  and  other  syphi- 
lides  are  usually  present.  Were  the  patient  suffering  from  a  well- 
marked  fever,  the  syphilitic  eruption  might  readily  be  taken  for  either 
varicella  or  varioloid,  according  to  its  type.  A  history  of  the  case, 
and  the  concomitant  signs  of  constitutional  syphilis,  should  quickly 
establish  the  proper  diagnosis. 

The  herpetic  form  of  the  vesicular  syphilide  exhibits  clusters  of 
vesicles  of  various  sizes,  either  irregularly  grouped  or  having  a  distinct 
circinate  arrangement. 

The  lesions  of  the  circinate  form  are  small,  are  not  persistent,  dry 
up  without  rupture,  and  leave  an  area  of  superficial  exfoliation  and 
raw-ham-colored  staining. 

The  diagnosis  from  ordinary  herpes  is  generally  made  without 
trouble.  Yet  at  times  the  syphilitic  nature  of  the  eruption  can 
be  determined  only  by  the  associated  signs  of  syphilis.  Although 
syphilitic  vesicles  as  such  do  not  persist  for  any  great  length  of 
time,  the  copper-colored  macules  or  pustules  left  after  the  ab- 
sorption or  rupture  of  the  ^^esicles  are  liable  to  remain  for  many 
months. 

Treatment. — The  treatment  of  vesicular  syphilides  consists  in  the 
administration  of  mercury,  supplemented  by  mercurial  baths  to  pre- 
vent the  vesicles  from  becoming  converted  into  pustules. 

Pustular  Syphilide. — The  syphilitic  pustule  may  be  small  or 
large,  and  either  of  these  varieties  may  be  acuminated  or  flat. 

The  lesions  are  commonly  placed  on  indurated  copper-colored 
bases ;  they  may  be  surrounded  by  an  extensive  dusky  areola. 

In  the  early  eruptions,  and  when  the  lesion  first  appears,  the  pus 


CONSTITUTIONAL  SYPHILIS.  871 

is  contained  between  tlie  raised  epiderm  and  the  true  skin ;  later, 
deeper  ulcers  may  be  formed. 

These  syphilides  very  closely  simulate  any  of  the  pustular  non- 
specific skin  eruptions.  They  are  prone  to  crust,  the  crusts  vary- 
ing from  a  dark-yellow  to  a  dark-green  or  brown-black  color,  and 
exhibiting,  when  raised  from  the  surface  of  the  lesion,  a  distinct 
punched-out  ulcer  covered  with  viscid  pus. 

When  the  pustular  lesions  heal,  they  leave  marked  pigmenta- 
tions, and,  unless  the  ulceration  is  purely  superficial,  permanent 
cicatrices. 

Pustules  commonly  appear  late  in  the  disease  ;  their  early  de- 
velopment is  usually  associated  with  a  severe  form  of  syphilis. 

The  pustular  syphihdes  may  develop  on  any  skin  surface ;  if  the 
lesions  are  few  in  number,  they  are  perhaps  more  frequently  noted 
on  the  face,  the  scalp,  and  the  legs. 

Any  of  the  syphilides  may  be  found  associated  with  pustular 
lesions,  and  even  when  the  predominant  eruption  is  papular  the  pus- 
tule may  be  found  at  the  same  time  in  all  its  forms  and  at  all  stages 
of  evolution.  An  early  pustular  eruption  is  especially  liable  to  be 
preceded  by  syphilitic  fever  of  an  intermittent  type,  with  its  associated 
symptoms  of  malaise,  pallor,  inability  to  concentrate  the  thoughts, 
headache,  insomnia,  articular  pains,  and  sternal  tenderness. 

The  pustular  syphilides  are  somewhat  obstinate  to  treatment,  are 
prone  to  recur,  and  are  more  frequently  followed  by  tertiary  mani- 
festations than  when  the  eruption  appears  in  a  macular  or  a  papular 
form.  (Bassereau.)  When  pustulation  has  been  unusually  well 
marked  during  the  secondary  stages  of  the  disease  the  tubercular 
and  gummatous  lesions  of  the  tertiary  stage  of  the  disease  exhibit  a 
marked  tendency  to  suppurate. 

Small  Acuminated  Pustular  Syphilide. — This  eruption  is  the  most 
superficial,  and  usually  in  its  time  of  appearance  the  earliest,  erup- 
tion of  this  group.  It  is  made  up  of  minute  miliary  pustules,  each 
situated  about  a  hair-follicle  or  the  opening  of  a  sebaceous  gland.  It 
is  followed  by  the  formation  of  small  yellowish  crusts,  leaving  a  pig- 
mented spot  surrounded  by  a  fringe  of  exfoliating  epithelium.  On  its 
first  appearance  the  eruption  usually  covers  a  large  surface,  may  be 
discrete  or  confluent,  and  exhibits  circinate  grouping.  Relapses  of 
this  syphilide  are  not  apt  to  appear  as  a  general  eruption,  but  rather 
the  lesions  will  be  grouped  in  certain  localities. 

When  the  lesions  become  confluent,  superficial  scabs  are  formed 
very  like  those  observed  in  impetigo.  The  eruption  about  the  lips  is 
sometimes  accompanied  by  a  warty  growth.     This  eruption  corre- 


g72  GEXITO-UPvINAEY   DISEASES  AND   SYPHILIS. 

spends  closely  to  the  small  vesicular  syphilide,  the  only  difference 
being  that  the  raised  epidermis  has  beneath  it  pus  instead  of  serum. 

This  pustular  syphilide  does  not  last  long.  Slight  crusting  takes 
place,  and  a  pigmented  spot  is  left  which  is  slow  to  disappear.  Some- 
times, and  this  is  particularly  true  of  the  relapses,  ulceration  takes 
place  and  a  permanent  cicatrix  is  left. 

Diagnosis. — The  diagnosis  is  founded  upon  the  pigmentation,  and 
is  usually  rendered  easy  by  the  fact  that  this  eruption  very  rarely 
appears  alone,  being  commonly  associated  with  papules  and  roseola. 

Large  Acuminated  Pustular  Syphiude  (Fig.  284). — This  eruption 
may  develop  suddenly,  or  may  form  slowly  with  fever.  When  the 
pustules  are  moderate  in  size,  they  so  closely  resemble  ordinary  acne 
that  the  term  syphilitic  acne  is  very  generally  employed  to  designate 
them.  The  individual  lesion  begins  as  a  macule,  which  quickly  be- 
comes converted  into  a  papule,  then  a  pustule,  commonly  placed 
about  a  hair-folhcle,  upon  a  papular,  infiltrated,  copper-colored  base. 
The  pustule  remains  for  one  or  two  weeks  before  rupturing.  Then 
crusts  are  formed,  which  in  dropping  off  expose  either  a  superficial 
ulcer  or,  more  commonly,  a  coppery  papule.  This  and  the  pigmenta- 
tion very  slowly  disappear ;  usually  there  is  scarring. 

Syphilitic  acne  may  appear  as  a  general  eruption  ;  more  commonly 
it  invades  the  scalp,  face,  and  trunk  ;  it  is  often  found  on  the  limbs. 

Diagnosis. — The  diagnosis  of  the  large  acuminated  pustular  syph- 
ilide will  be  founded  mainly  on  the  presence  of  other  signs  of  syphilis, 
particularly  the  other  syphilides.  Ordinary  acne  commonly  appears 
on  the  face,  chest,  and  back,  about  the  age  of  puberty,  being  rare 
in  late  life,  and  on  the  removal  of  the  crusts  does  not  exhibit  the 
coppery,  lenticular  papule  of  syphilis.  An  acne-like  eruption  con- 
fined to  the  trunk  and  the  legs  strongly  suggests  syphilis. 

Variola  is  a  uniform  eruption,  the  lesions  all  corresponding  to  the 
papular,  then  to  the  pustular  type.  It  is  acute,  follows  definite  well- 
marked  prodromes,  runs  its  course  in  a  few  days,  and  is  attended  with 
very  pronounced  constitutional  symptoms.  The  dorsal  surfaces  of 
the  wrists  and  hands  and  the  palms  and  soles  are  nearly  always 
affected  with  papules  followed  by  pustules,  and  this  disease  occurs 
only  in  those  not  protected  by  vaccination.  There  is  little  danger  of 
mistaking  this  eruption  for  a  pustular  syphiloderm.  An  error  the  re- 
verse of  this  has  been  made  many  times,  syphilitic  patients  having 
been  sent  to  small-pox  hospitals.  A  diagnosis  can  be  made  at  times 
only  after  one  or  two  days'  observation. 

Small,  Flat  Pustular  Syphilide. — The  lesions  of  this  form  of 
syphilide  closely  resemble  those  of  impetigo.     They  are  more  com- 


Fig.  284. 


Large  pustular  syphilide. 
(From  the  collection  of  photogiaphs  of  Dr.  George  Henry  Fox.) 


-J 


CONSTITUTIONAL   SYPHILIS. 


873 


Fio.  286. 


mon  than  the  acuminated  syphihdes.  Small,  flat,  split-pea-sized  pus- 
tules form  on  somewhat  elevated  copper-colored  bases.  These 
pustules  shortly  rupture,  and  are  followed  by  rather  thick,  adherent, 
yellowish  or  greenish  crusts.  These  lesions  may  be  discrete,  may 
exhibit  a  circinate  grouping,  or 
may  be  confluent,  forming  irregu- 
larly shaped  crusts  (pustulo-crus- 
taceous).  (Fig.  285.)  In  the 
latter  periods  of  the  disease  this 
eruption  commonly  appears  in 
the  form  of  irregular  patches, 
often  presenting  a  narrow  crusted 
circinate  border,  which,  spreading 
peripherally,  encloses  an  area  of 
pigmented,  scarred,  or  normal 
skin.     (Fig.  286.) 

Beneath  the  crusts  of  syphi- 
litic impetigo  are  found  ulcers. 
These  may  be  superficial  or  deep, 
the  latter  variety  appearing  late 
in  the  disease.  These  ulcers  on 
healing  leave  depressed,  pig- 
mented cicatrices,  which  are 
prone  to  scale  for  months.  The 
pigmentation  finally  fades,  the 
scar  remaining  white. 

When  syphilitic  impetigo  ap- 
pears as  an  early  general  erup- 
tion, it  may  last  but  a  few  weeks. 
The  late  confluent  circinate  and 
serpiginous  forms  are  extremely 
chronic. 

The  favorite  seat  is  the  face, 
especially  in  the  hairy  portions, 

as  the  beard  and  the  eyebrows,  and  about  the  nostrils  and  lips.  (Figs. 
288,  289.)  They  also  develop  frequently  on  the  scalp  (Fig.  287),  the 
chest,  and  the  outer  surfaces  of  the  arms  and  legs.     (Fig.  290.) 

Diagnosis. — The  diagnosis  of  small,  flat  pustular  syphiloderm  is 
sometimes  not  possible  from  the  inspection  of  the  lesions  alone,  the 
latter  corresponding  very  closely  to  those  of  pustular  eczema  and 
impetigo. 

The  crusts  of  pustular  eczema  on  being  raised  show  an  excoriation, 


Pu^liUar  syphilids  (pustuiij-cnistaceous). 

(From  the  collection  of  pliotogiaplis  of  Dr.  George 

Henry  Fox.) 


874 


GENITO-URINARY    DISEASES    AND   SYPHILIS. 


and  the  disease  is  distinctly  more  inflammatory  in  type  ttian  the 
syphiloderm.  The  pustule  of  impetigo  is  discrete,  not  placed  on  an 
infiltrated  base,  and  exhibits  no  copper-colored  areola. 


Fig.  287. 


Pustular  syphilide. 
(From  tlip  collection  of  pliotogriiplis  of  Dr.  George  Henry  Fox.; 

It  is  mainly  by  the  presence  or  the  absence  of  associated  signs 
of  syphilis  that  a  diagnosis  is  to  be  made. 

Large,  Flat  Pustular  Syphilide.— The  lesions  of  this  syphilide 
closely  resemble  ecthyma:  hence  the  eruption  is  commonly  called 
syphilitic  ecthyma.  It  appears  in  the  form  of  large,  flat  pustules, 
varying  from  a  quarter  of  an  inch  to  an  inch  and  a  half  in  diameter. 
(Fig.  291.)  The  lesion  commonly  begins  as  a  raised,  dusky  red, 
slightly  inflamed,  and  indurated  area,  which  quickly  suppurates,  the 
pus  raising  the  epiderm  but  slightly,  and  forming  a  large,  flat,  not 
very  tense  pustule,  which  shortly  crusts. 

The  lesion  may  remain  superficial,  hmited,  and  only  moderately 
crusted,  exposing,  on  exfoliation  or  removal  of  the  scab,  an  erosion 
or  a  shahow  ulceration,  or  it  may  extend  both  in  depth  and  in  circum- 
ference. 

The  superficial  form  occurs  towards  the  end  of  the  first  year  of 
constitutional  syphilis  ;  it  is  amenable  to  treatment,  and  particularly 
affects  the  shoulders,  back,  and  extremities. 


o    ^ 
■*  o 


Fig.  290. 


Flat  pustular  and  papulo-squamous  sypliilide. 


CONSTITUTIONAL   SYPHILIS. 


875 


In  the  deep  form  of  syphilitic  ecthyma  the  ulceration  is  progres- 
sive in  ah  directions.  The  crust  increases  in  thickness  and  extent, 
the  material  for  it  being  furnished  in  the  continued  suppuration  of 
the  extending  ulcer ;  it  projects  from  the  surface  in  the  form  of  a 
greenish  or  brown-black  cone,  often  exhibiting 
distinct  stratification.  This  thick,  conical,  adhe- 
rent crust  commonly  overlaps  the  raw  surface 
beneath ;  sometimes  its  base  is  sunk  in  the  ulcer 
and  is  completely  surrounded  by  unhealthy  granu- 
lations. 

Lesions  made  up  of  these  dark,  raised,  conical, 
laminated  crusts,  seated  upon  deep  ulcers,  and 
surrounded  by  reddened,  indurated  areas,  are 
called  rupial.  When  the  ulceration  extends  lat- 
erally and  does  not  grow  materially  deeper,  the 
crust  may  be  depressed  in  the  centre  and  elevated 
about  the  margins. 

When  the  thick  crusts  of  deep  ecthyma  are 
removed,  punched-out  ulcers  covered  with  thick 
greenish  or  yellow  pus  are  found.  These  ulcers 
are  rounded  or  circular,  and  usually  discrete  and 
few  in  number.  When  the  pustules  are  closely 
grouped  they  commonly  become  confluent,  the 
outline  of  the  resultant  lesion  being  circinate. 

The  chronic  crusted  lesions  of  the  pustulai" 
syphihdes  are  termed  pustulo-crustaceous.  When 
they  are  confluent,  spreading  widely  in  circinate 
forms,  and  are  destructive,  they  are  termed  ser- 
piginous.    (Fig,  292.) 

Diagnosis. — The  diagnosis  of  syphilitic  ec- 
thyma from  simple  ecthyma  will  be  based  largely 
upon  the  evolution  of  the  lesions,  which  in  non-  ^y^T''\  °^  ^"'  ^'°'^' 

^       _  _  '  Henry  Jox.) 

specific  disease  develop  rapidly  and  run  their 
course  in  a  few  weeks,  are  attended  with  heat,  pain,  and  other  symp- 
toms of  acute  inflammation,  form  brownish,  not  very  thick,  laminated 
crusts,  and  exhibit  on  removal  of  the  latter  superficial  ulceration  in 
place  of  the  punched-out  unhealthy  ulcer  of  syphilis.  In  ecthyma 
the  eruption  is  uniform,  and  there  are  no  coexistent  signs  of  syphilis. 

Deep  ecthyma  leaves  permanent  cicatrices.     Rupial  and  the  other 
forms  of  deep  syphilitic  ecthyma  appear  as  late  lesions  of  syphilis. 

All  the  late  pustular  eruptions,  particularly  those  which  are  deep, 
yield   to  specific   treatment   slowly.      They  usually  develop  in   the 


Large,  flat  pustular  syphi- 
lide  (ecthyma). 
(From    the  collection  of 


876 


GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 


cachectic  and  poorly  nourished,  and  indicate  tonic  supporting  treat- 
ment in  addition  to  specific  medication  and  local  applications. 


Fig.  '2'.)2. 


Serpiginous  syphilide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


Pigmentary  Syphilide. — The  pigmentai-y  syphiiides  are  quite 
distinct  from  the  stains  secondary  to  the  f)apular  or  pustular  eruption 
of  syphihs.  They  are  dependent  upon  a  primary  excess  of  pigment, 
which  may  subsequently  give  place  to  leucoderma,  or  loss  of  color. 
The  lesion  appears  in  three  forms  (Taylor) : 

1.  As  rounded,  oval,  or  irregular  plaques,  with  sharply  defined  or 
Jagged  borders,  varying  from  light  brown  to  deep  brown. 

2.  As  diffuse  pigmentation,  which  becomes  the  seat  of  leucoderma- 
tous  changes,  appearing  first  as  small  spots,  which  gradually  increase 
in  size.     (Retiform  pigmentation.) 

3.  As  abnormal  distribution  of  pigment,  some  parts  of  the  skin  ap- 
pearing lighter,  others  darker,  than  normal.     (Marbled  pigmentation.) 


CONSTITUTIONAL   SYPHILIS.  877 

The  pigmentation  is  unaffected  by  pressure,  the  patches  are  not 
above  the  surface  of  the  surrounding  skin,  and  there  is  no  exfohation. 
It  is  usually  a  secondary  manifestation  of  the  disease,  developing  about 
the  sixth  month,  though  it  is  at  times  observed  as  late  as  the  second 
or  the  third  year.  It  is  more  common  in  females  before  middle  age. 
Its  seats  of  preference  are  the  sides  of  the  neck,  though  it  may  be 
found  elsewhere,  as  the  chest,  the  forehead,  and  the  flexor  surfaces 
of  the  limbs.  It  lasts  for  several  months,  then  gradually  fades,  the 
skin  resuming  its  natural  color.  Treatment  seems  to  have  no  effect 
upon  it. 

Tubercular  Syphilide. — Tubercular  syphilides  appear  as  pin- 
head-  or  almond-sized,  rounded  or  flat,  hard,  copper-colored  infiltra- 
tions, which  invade  the  entire  thickness  of  the  skin,  differing  in  this 
respect  from  the  papular  eruption,  and  resembling,  except  in  the 
absence  of  inflammatory  symptoms,  a  forming  furuncle. 

The  eruption  may  be  generalized,  or  may  occur  in  patches  on  cer- 
tain parts  of  the  body ;  it  may  be  discrete  or  confluent ;  it  may  be 
circinate,  serpiginous,  or  irregularly  grouped.  It  may  ulcerate,  or  the 
infiltrate  may  become  absorbed.  In  either  case  there  is  usually 
permanent  scarring. 

A  discrete  general  eruption  is  rare  ;  it  occurs  in  the  late  secondary 
or  in  the  tertiary  period  of  the  disease,  rarely  before  the  end  of  the 
first  year,  though  exceptionally  it  may  develop  within  six  months  of 
the  chancre. 

The  eruption  commonly  appears  grouped  on  one  or  more  regions 
of  the  body,  the  indurated  lesions  having  a  tendency  to  coalesce  and 
form  circular,  scaling,  or,  if  ulceration  takes  place,  eroding  patches. 
Lesions  of  this  kind  may  develop  twenty,  thirty,  or  forty  years  after 
the  appearance  of  a  chancre.     (Bassereau.) 

Though  the  tubercular  syphilide  may  attack  any  portion  of  the 
skin  surface,  its  seats  of  preference  are  the  face,  particularly  about  the 
lips  and  nose,  the  forehead,  the  ears,  the  back,  and  the  legs.  The 
course  of  this  eruption  is  extremely  chronic  ;  it  is  prone  to  relapse. 

The  Non-Ulcerating  Tubercular  SYPHiLmE. — The  hard,  dusky 
red,  chronic,  scaling,  tubercular  eruption,  when  general  and  discrete, 
cannot  well  be  confounded  with  any  other  lesion,  except  the  papular 
syphilide  ;  an  error  of  no  great  moment,  but  one  which  is  avoided 
by  noting  that  the  tubercle  involves  the  entire  thickness  of  the  skin 
and  appears  at  a  later  stage  of  the  disease  than  does  the  papule. 
When  grouped,  the  individual  lesions  of  each  group  are  usually  much 
smaller  than  the  lesions  of  the  discrete  general  eruption ;  they  tend 
to  coalesce,  forming  circular  or  irregular  patches  (Figs.   293,  294), 


878 


GENITO-UKINARY   DISEASES   AND  SYPHILIS. 


which  increase  in  size  peripherally,  while  absorption  and  more  or 
less  atrophy  of  the  skin  take  place  in  the  centre.     This  results  in  a 


Fig.  293 


Non-ulcerating  tubercular  syphilide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 

raised  circular  margin  made  up  of  tubercles  so  merged  that  they 
can  rarely  be  distinguished  as  separate  tumors,  within  which  lies 
the  depressed,  pigmented,  atrophic  skin.     (Fig.  295.)     These  circles 

Fig.  295. 


Non-ulcerating  tubercular  syphUide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 

vary  in  diameter  from  a  fraction  of  an  inch  to  four  or  five  inches. 
The  surface  of  the  non-ulcerating  tubercle  may  be  dry  and  glistening. 
More  commonly  there  is  a  covering  of  branny  scales  (tuberculo- 
squamous  syphilide).  (Fig.  296.)  These  lesions  develop  Avithout 
subjective  sensations,  except  when  situated  upon  the  face.  After  an 
alcoholic  debauch  there  may  be  marked  local  inflammatory  phenom- 
ena in  lesions  thus  situated. 

The  tubercles  are  resistant  to  treatment,  often  lasting  for  months. 
They  may  form  permanent  scars,  incident  to  a  process  of  interstitial 


Fin.  294. 


Tubercular  syphilide.    (Jox.) 


■^M&^^^i^ 


^ 


CONSTITUTIONAL   SYPHILIS. 


879 


absorption.     These  scars  are  at  first  brown  or  copper-colored ;  ulti- 
mately they  become  white. 

Fig.  296. 


Tubercular  (squamous)  syphilide. 
(From  the  coUectiou  of  phutograijhs  of  Dr.  George  Henry  Fox.) 

Ulcerating  tubercular  syphilides  are  much  more  serious  than  the 
dry  tubercular  eruption,  both  in  their  immediate  effects  and  from  a 
prognostic  stand-point.  The  dry  lesion  after  persisting  for  months 
may  break  down  ;  more  commonly  the  tubercle  from  the  first  shows 
a  tendency  to  crust.  This  form  of  eruption  is  rarely  general,  com- 
monly affects  certain  regions  of  the  body,  exhibits  a  round  grouping, 
and  may  invade  a  large  surface. 

The  ulceration  may  be  superficial,  attended  by  a  slight  scabbing 
and  followed  by  very  little  scarring ;  or  it  may  be  deep,  invading  the 
entire  thickness  of  the  skin  (Figs.  297,  298),  may  be  covered  by  thick 
scabs  (Fig.  299),  and  may  be  followed  by  dense  cicatrices,  which  cause 
both  disfigurement  and  disability. 

The  ulceration  extends  slowly,  healing  with  the  formation  of  scar- 
tissue  in  one  place  while  breaking  down  is  taking  place  in  another. 
This  process  may  continue  for  months  or  years,  the  diseased  area 
forming  circles,  broad  bands,  or  irregular  figures  (Fig.  300),  and  in- 
volving a  large  surface.     Thus  the  entire  face  may  be  disfigured  by 


GENITO-URINAEY   DISEASES   AND   SYPHILIS 


the  lesion.  This  form  is  cahed  serpiginous.  It  is,  of  course,  not 
exempt  from  the  microbic  invasion  to  which  all  open  surfaces  are 
exposed,  and  as  a  result  of  infection  may  become  phagedenic,  the 
ulceration  extending  with  extreme  rapidity  and  destroying  a  large 
amount  of  tissue  in  a  few  hours. 

The  face  and  back  are  the  favorite  seats  of  serpiginous  syphihdes. 

As  in  other  forms  of  syphilitic  skin  eruptions,  in  place  of  ulceration 
and  destruction  there  may  be  hypertrophy,  the  skin  papillae  growing 
from  the  ulcerated  surface  of  a  tubercle  to  form  a  pus-secreting  cauli- 
flov/er  growth. 

Frequently  the  cicatrices  of  ulcerating  tubercular  syphilides  are 
pathognomonic  of  the  specific  lesions  ;  in  the  midst  of  the  large  scars 
can  be  seen  the  small,  depressed,  round  cicatrices  of  the  individual 
tubercle. 

Diagnosis. — The  diagnosis  of  the  tubercular  syphilide  must  be 
made  from  lupus  vulgaris.  Lepra  and  carcinoma  are  also  closely 
simulated  by  this  syphilide. 

The  main  diagnostic  points  between  ulcerating  tubercular  syphihde 
and  lupus  vulgaris  are  as  follows : 


Tubercular  Syphilide. 

Tubercular  syphilide  generally  occurs 
in  adults  who  give  a  history  of  syph- 
ilis or  exhibit  signs  of  other  syphilitic 
lesions. 

Begins  as  a  copper-colored  or  brownish 
tubercle,  which  becomes  a  character- 
istic ulcer  in  one  or  two  months. 

The  tubercles  are  of  a  brownish-red  or 
coppery  color,  and  are  comparatively 
large. 

The  skin  is  distinctly  infiltrated  through 
its  entire  thickness. 

Ulcers,  if  distinct,  are  small,  circular, 
punched  out.  If  confluent,  they  in- 
volve a  large  area.  The  secretion 
may  be  copious  and  offensive. 

The  crusts  are  bulky  and   greenish  or 

brownish  black. 
The  scabs  are  irregular  in  shape   and 

attachment. 

The  scars  are  soft,  white,  and  circular. 
Local  treatment  is  ineffective.  Inter- 
nal specific  treatment  effects  a  cure. 


Lupus  Vulgaris. 

Lupus  vulgaris  generally  occurs,  or  at 
least  first  appears,  before  the  twen- 
tieth year  of  life,  without  history  or 
signs  of  syphilis. 

Begins  as  a  tubercle,  which  does  not 
ulcerate  to  the  same  extent  for  many 
months  or  even  years. 

The  tubercles  are  often  translucent,  of 
lighter  color,  and  are  small. 

The  infiltration  of  the  skin  is  not  so 
marked. 

Ulcers  are  rarely  distinct.  They  are 
superficial,  are  not  punched  out,  ex- 
hibit no  regular  form,  and  seldom  in- 
volve large  areas.  The  secretion  is 
slight  and  not  offensive. 

The  crusts  are  thin  and  dark  red. 

The  scabs  are  arranged  more  regularly, 
attached  in  the  centre,  and  loosened 
at  the  edges. 

The  scars  are  distorted,  irregular,  and 
puckered.  Active  surgical  interven- 
tion is  effective.  Internal  specific 
treatment  is  without  effect. 


Fig.  301. 


Syphilitic  rupia  following  the  bullous  syphilide. 


CONSTITUTIONAL    SYPHILIS.  881 

Aside  from  the  history  of  the  case,  the  most  important  points  to 
be  considered  in  differentiating  between  lupus  and  syphilis  are  the 
early  age  at  which  lup.us  begins,  its  very  slow  course,  its  superficial 
ulcerations,  and  its  cicatrices,  which  exhibit  neither  the  character- 
istic coppery  stains  nor  the  many  small,  depressed,  circular  scars  of 
ulcerating  tubercular  syphilides. 

'  Cancer  is  sometimes  closely  simulated  by  the  tubercular  syphilide. 
The  slow  growth,  the  steady  progress  without  attempt  at  cicatriza- 
tion, the  scanty  discharge,  the  lancinating  pains,  the  lymphatic  in- 
volvement, the  absence  of  signs  or  history  of  syphilis,  and  the  resist- 
ance to  specific  treatment,  are  symptoms  which  will  generally  lead 
to  a  correct  diagnosis. 

The  Bullous  Syphilide. — This  eruption  usually  appears  as 
rounded  or  oval,  discrete  blebs  surrounded  by  a  slight  areola,  varying 
in  size  from  that  of  a  split  pea  to  that  of  a  penny.  The  clear  serum 
contained  within  the  bleb  shortly  becomes  turbid  and  blood-stained 
or  even  distinctly  purulent.  On  rupture  of  the  blebs,  the  contents 
form  dark-yellowish  or  greenish-black  scabs.  These,  growing  from 
the  bottom,  by  the  drying  of  the  freshly  secreted  pus  of  the  slowly 
enlarging  ulcer,  finally  result  in  raised,  conical,  imbricated  crusts, 
often  half  an  inch  to  an  inch  in  height,  and  sometimes  twice  as  much 
in  diameter.  (Fig.  301.)  These  crusts  are  adherent,  and  usually  over- 
lap and  conceal  the  underlying  ulcer,  though  sometimes  they  may  be 
set  in  the  latter  as  a  watch-crystal  is  set  in  its  rim.  Unless  mechani- 
cally disturbed,  they  generally  remain  till  the  ulcer  is  healed.  If  they 
are  removed,  a  deep,  punched-out,  unhealthy,  granulating  surface  is 
exposed,  covered  with  black,  sanious  pus. 

The  bullous  syphiloderm  is  commonly  found  in  broken-down  sub- 
jects, and  is  significant  of  an  inveterate  form  of  syphilitic  poisoning. 
The  crusted  ulcers  following  bullae  or  pustules  form  the  typical  rupial 
lesion.  The  crusts  of  rupia  are  large,  and  are  thicker  and  darker 
than  those  of  any  of  the  syphilides.  The  ulceration  involves  the 
entire  thickness  of  the  skin,  and  often  extends  over  a  large  surface. 

The  scars  left  by  rupia  are  similar  to  those  of  deep  ecthyma. 
The  eruption  is  encountered  in  the  tertiary  stage  of  the  disease,  and 
is  one  of  the  most  characteristic  lesions  of  syphilis. 

The  Gummatous  Syphilide. — Though  gummata  of  the  skin 
exceptionally  appear  in  the  first  six  months  of  syphilis,  in  such  cases 
indicating  a  grave  form  of  the  disease,  they  commonly  develop  three 
or  four  years  after  the  chancre. 

Gumma  differs  from  the  lesions  already  described  in  the  fact  that 
it  is  a  true  tumor  or  granuloma,  which,  having  once  developed,  in 

56 


882 


GENITO-UKIXAEY    DISEASES   A^D   SYPHILIS. 


whatever  way  it  terminates   permanently  affects   the    seat  of  mva- 
sion. 

The  favorite  locahties  of  the  gummatous  syphihdes  are  the  face, 
particularly  the  forehead,  arms,  forearms,  the  anterior  surface  of  the 
tibia,  particularly  the  upper  third,  the  skin  overlying  the  sternum  and 
clavicle,  the  scrotum,  the  penis,  the  external  genitalia  of  women. 

Fig.  302. 


>--^S.*il^, 


Gummatous  syphilide. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 

Gummata  of  the  skin  commonly  appear  as  rounded,  painless,  sub- 
cutaneous nodules,  freely  movable,  and  varying  in  size  from  that  of 
a  pea  to  that  of  a  cherry.  These  slowly  grow,  reddening,  infiltrating, 
and  softening  the  superficial  layers  of  the  skin  and  breaking  down  to 
form  deep,  undermined,  sloughing  ulcers.  (Figs.  302,  303,  304.) 
Sometimes  the  gumma  begins  as  a  circumscribed  infiltration  of  the 
skin  instead  of  a  distinct  subcutaneous  tumor. 

The  gumma  goes  through  the  stages  of:  1.  Formation,  usually 
of  long  duration  and  unattended  by  pain.  2.  Softening,  fluctuation 
being  felt  when  the  tumor  has  reached  its  full  size  (from  that  of  an 
almond  to  that  of  a  hen's  egg).  3.  Ulceration ;  the  skin  becomes 
discolored  and  perforated,  and  a  small  cfuantity  of  puriform,  gummy 
liquid  is  discharged.  4.  Reparation :  after  extrusion  of  the  slough 
granulations  form,  growing  centrally  from  the  periphery  of  the  ulcer. 

When  the  gumma  opens  there  is  at  once  an  escape  of  mucilagi- 
nous liquid.  The  partially  disorganized  infiltrate  adheres  by  its 
deeper  portions  to  the  subcutaneous  cellular  tissue,  and  is  subse- 
quently thrown  off  in  the  form  of  sloughs.  By  the  process  of  ulcera- 
tion a  numt)er  of  contiguous  gummata  may  coalesce,  forming  one 
huge  cavity,  with  irregular  sloughing  walls. 


CONSTITUTIONAL   SYPHILIS. 


880 


Though  the  stage  of  formation  is  slow  and  painless,  the  patient 
often  noticing  the  tumor  only  by  accident,  softening  and  ulceration 
may  progress  with   great   rapidity.     Thus,  Bassereau  states  that  a 


Fig.  303. 


Fig.  304. 


Single  ulcerating-  gumma. 


Ulcerating  gummata  becoming  confluent. 

(From  the  collection  of  plioti "graphs  of 

Dr.  Gsorge  Henry  Tox.) 


small,  indolent,  subcutaneous  nodule  of  the  nose  or  ear  has  In  a 
single  night  undergone  extensive  destructive  ulceration,  producing 
permanent  disfigurement. 

The  gumma  may  be  single  or  multiple.     In  the  latter  case  there 
are  rarely  more  than  half  a  dozen.     (Fig.  305.)    Exceptionally  several 


884 


GENITO-UEI^fAEY   DISEASES   AND   SYPHILIS. 


dozen  may  develop,  either  simultaDeously  or  following  one  another, 
usually  showing  a  circular  or  circinate  grouping  and  exhibiting  a 
tendency  to  coalesce,  forming  a  diffuse  infiltration,  which  on  ulcera- 
tion may  discharge  by  several  openings  through  the  blue  undermined 
skin. 

The  middle  of  the  forehead  is  a  favorite  seat  of  gummata.     One 
or  several  nodules  may  develop.     They  commonly  involve  the  under- 


FiG.  305. 


Multiple  gTimmata  of  the  leg. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 

lying  bone,  producing  caries,  which  may  extend  through  its  entire 
thickness,  exposing  the  dura.  Exceptionally  there  develops  a  deep 
and  diffuse  infiltration  of  the  face,  causing  great  thickening  of  the  skin 
and  presenting  the  appearance  of  leontiasis.  Acute  inflammation  of 
this  infiltrate  is  especially  liable  to  occur  in  drunkards,  and  leads  to 
extensive  destruction  of  tissue  and  consequent  deformity,  and  ex- 
ceptionally  to   violent   hemorrhage   from    erosion   of  blood-vessels. 


CONSTITUTIONAL   SYPHILIS. 


885 


Fig.  306. 


These  gummatous  infiltrations  are  sometimes  transformed  to  tuber- 
culous or  cancerous  lesions. 

Gummata  of  the  extremities  may  be  single  or  multiple.  As  they 
appear  on  the  leg  they  are  commonly  multiple,  and  have  for  their  seats 
of  predilection  the  anterior  and  lateral  surfaces  of  the  upper  third 
and  the  malleolar  regions.  When 
placed  here  they  break  down  readily 
and  are  subject  to  infectious  inflam- 
mations. (Fig.  306.)  They  are  ex- 
tremely obstinate  to  treatment,  and 
ultimately  assume  the  chronic  in- 
durated appearance  of  ulcers  due  to 
other  causes,  particularly  when  they 
are  near  the  malleoli.  (Fig.  307.) 
Gummatous  syphihdes  when  they 
develop  over  the  clavicle  and  ster- 
num are  often  associated  with 
underlying  periostitis  and  ostitis. 
Because  of  this,  when  they  have 
ulcerated  they  are  difficult  to  cure. 

The  prepuce  may  be  affected  by 
eitlier  diffuse  gummatous  infiltration 
or  individual  nodules.  In  either 
case  the  diagnosis  from  primary 
lesion  can  be  made  from  the  fact 
that  infiltration  preceded  ulceration. 
Single  ulcerating  gummatous  lesions 
of  the  glans  penis  may  exactly  simu- 
late chancre.  The  inguinal  glands 
do  not,  however,  share  the  charac- 
teristic enlargement  of  the  primary  lesion,  and  the  development 
of  the  lesion  and  the  history  of  the  case  usually  point  to  the  true 
diagnosis. 

The  gummatous  ulcer  may  become  serpiginous  or  phagedenic. 
The  necrosis  involves  not  only  the  imperfectly  organized,  round- 
cehed  infiltrate  of  gumma,  but  also  the  anatomically  associated  tissues, 
often  exposing  and  eroding  bone,  destroying  tendons  and  muscles, 
opening  mucous  channels,  and  resulting  in  disfiguring  and  disabling 
cicatrices.  In  the  scrofulous,  gummatous  ulcers  are  particularly  per- 
sistent. Exceptionally  these  ulcers  exhibit  papillary  outcroppings 
presenting  an  appearance  much  like  that  of  epithelioma.  From  the 
scars  of  these  ulcers  epitheliomata  sometimes  develop. 


Sloughing  gumma  of  the  leg 


886 


GENITO-UEINAEY    DISEASES   AND   SYPHILIS. 


Diagnosis. — A  history  of  syphilis,  or  concomitant  signs  of  the  dis- 
ease, and  the  typical  development  of  a  painless  infiltration  at  the  seats 
of  predilection,  should  establish  the  diagnosis  of  gumma.  As  this 
lesion  is  a  late  tertiary  symptom,  it  may  stand  alone  as  an  expression 
of  the  constitutional  disease,  since  too  often  a  clear  history  is  wanting 
both  of  preceding  syphilis  and  of  the  mode  of  onset  of  the  gumma. 


Fig.  307 


Ulcerating  gunmiata  of  the  malleolar  region. 
(From  the  collection  of  pbotogra|ilis  of  Dr.  George  Henry  Fox.) 

When  the  tumor  is  seen  during  the  stage  of  infiltration  it  may  simulate 
benign  tumor  or  sarcoma  so  closely  that  diagnosis  can  be  made  only 
by  the  therapeutic  test  or  by  keeping  the  growth  under  observation 
a  sufficient  length  of  time  to  note  its  mode  of  development.  The 
alleged  cure  of  sarcoma  by  mercury  clearly  shows  the  difficulty  in 
making  a  correct  diagnosis  from  one  examination. 

When  the  gumma  has  ulcerated  and  exhibits  papillary  outgrowths 
it  may  resemble  epithelioma  almost  exactly.  The  mode  of  onset  is, 
however,  different,  epithelioma  beginning  as  a  wart  or  an  ulcer,  and 
not  as  an  infiltration.     Microscopical  examination  of  a  portion  of  the 


CONSTITUTIONAL  SYPHILIS.  887 

/emoved  growth  and  the  effect  of  specific  treatment  should  definitely 
and  promptly  settle  the  diagnosis. 

The  cicatrices  of  healed  gummata  are  depressed  and  adherent  to 
deeper  structures. 

SYPHILITIC   AFFECTIONS   OF  THE   APPENDAGES   OF   THE   SKIN. 

Syphilitic  Alopecia  and  Onychia. — Syphilitic  alopecia  ap- 
pears with  the  early  secondary  symptoms, — i.e.,  about  the  third  month 
from  the  development  of  the  chancre  ;  it  may  develop  much  later. 
There  may  be  total  or  partial  loss  of  the  hair.  Total  loss  is  rare. 
Partial  loss  may  develop  in  the  form  of  a  general  shedding,  the  hair 
coming  out  readily  and  the  resultant  appearance  of  the  scalp  simu- 
lating that  of  advancing  baldness  from  other  causes.  More  charac- 
teristic is  the  shedding  of  hair  in  irregular,  usually  rounded,  scaling 
patches,  giving  the  scalp  a  typical  moth-eaten  appearance.  Both  the 
general  and  the  circumscribed  alopecia  are  often  associated  with 
papular  and  papulo-pustular  lesions  of  the  scalp.  As  has  been  stated, 
the  prognosis  of  these  forms  of  alopecia  is  favorable,  the  hairs  grow- 
ing again  on  the  absorption  of  the  infiltrate  which  interferes  with 
their  nutrition. 

Circumscribed  alopecia  due  to  ulcerating  and  tubercular  syphilides 
is  permanent,  since  the  lesions  entirely  destroy  the  hair-folhcles. 
(Fig.  308.) 

The  diagnosis  of  specific  alopecia  is  founded  on  the  rapidity  of 
the  process,  the  history  of  syphiHs  and  associated  symptoms  of  the 
disease,  and  the  patchy,  moth-eaten  appearance  of  the  scalp,  the  bare 
spots  showing  prominent  follicles  and  a  scaling  surface.  When  the 
alopecia  is  partial,  shedding  of  the  hair  is  most  noticed  over  the 
posterior  portions  of  the  scalp,  thus  differing  from  ordinary  baldness. 

In  addition  to  vigorous  constitutional  treatment,  shampooing, 
massage,  and  active  counter-irritation  are  indicated. 

Onychia  is  due  to  the  influence  of  the  syphilitic  poison  on  the 
matrix  of  the  nail  and  on  the  periungual  and  subungual  epidermic 
tissue.  The  term  paronychia  signifies  that  the  tissues  surrounding 
the  nails  are  involved  primarily.  The  nails  become  dry,  brittle, 
lustreless,  and  break  on  the  least  pressure  (friable  onychia).  They 
may  be  fissured  and  loosened  from  their  matrices,  to  be  finally  shed 
completely,  giving  place  to  a  new  naih  Sometimes  the  nail  becomes 
greatly  discolored,  thickened,  and  distorted  (onychia  hypertrophica). 

These  forms  of  onychia  are  usually  observed  in  the  early  secondary 
period  of  syphilis.  They  are  painless,  non-inflammatory,  and  produce 
no  permanent  deformity,  the  new  nail-tissue  being  healthy  in  appear- 


GENITO-URINAKY    DISEASES  AND   SYPHILIS. 

ance  when  active  constitutional  treatment  has  succeeded  in  over- 
coming the  specific  virus.  Tlie  nails  of  the  fingers  are  more  frequently 
attacked  than  those  of  the  toes. 

The  treatment  is  constitutional.  Local  treatment,  except  cleanli- 
ness and  protection,  is  without  effect. 

Paronychia,  or  inflammation  in  the  tissues  around  the  nails,  may 
be  dry  or  moist. 

The  dry  paronychia,  or  non-ulcerative  form  of  the  affection,  is- 

Fig.  308. 


Syphilitic  alopecia  foUomng  ulcerative  lesions. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


commonly  associated  with  the  papular  syphiMdes.  It  begins  either 
as  a  papule  which  involves  the  cutaneous  folds,  occasioning  horny 
thickening  and  exfoliation  of  the  epidermis,  or  as  an  infiltration 
surrounding  the  nail,  much  as  would  an  ordinary  "  run-around," 
except  that  it  is  chronic  in  its  course,  painless,  and  exhibits  a  deep 
coppery  color.  In  either  case  the  nail  is  often  brittle,  cracked,  and 
deformed. 

3foist  paronychia,  or  the  ulcerating  form  of  the  affection,  is  often. 


CONSTITUTIONAL   SYPHILIS.  889 

associated  with  the  vesicular  or  pustular  syphilides.  It  begins  as 
in  the  dry  form,  but  goes  on  to  ulceration,  the  inhltrate  becoming 
fissured  and  suppurating.  As  a  result  there  is  found  about  the 
periphery  of  the  nail,  and  frequently  undermining  it,  an  unhealthy 
ulcer,  the  granulations  of  which  may  become  exuberant.  There  may 
be  swelling  of  the  extremity  of  the  digit  as  marked  as  that  observed 
in  felon. 

Diagnosis. — The  diagnosis  of  syphilitic  paronychia  is  founded  on 
the  painless,  chronic  course  of  the  affection,  the  absence  of  acute 
inflammatory  symptoms,  and  the  presence  of  other  signs  of  syphilis. 

The  nail  is  frec{uently  shed,  and,  if  the  ulceration  has  been  suffi- 
ciently deep  to  destroy  the  matrix,  will  not  be  reproduced.  It  usually 
grows  again,  but  is  shrivelled  and  deformed.  The  infiltrate  may 
remain  for  many  months. 

Treatment. — The  treatment  of  ulcerating  paronychia  is  primarily 
that  suited  to  the  management  of  secondary  syphihs.  The  local 
treatment  must  be  conducted  on  general  surgical  principles.  Pro- 
longed immersion  in  weak,  hot  bichloride  solution  (1  to  2000), 
followed  by  the  application  of  moist  compresses  wrung  out  of  the 
same  solution  and  kept  from  drying  by  the  application  of  waxed 
paper  or  oiled  silk,  will  aid  in  rendering  the  ulcerating  surface  clean 
and  will  promote  healing. 

When  the  granulations  are  indolent  and  exuberant,  forming  a 
mushroom-like  growth,  they  may  be  thoroughly  curetted,  or  their 
surface  may  be  sprinkled  with  dry  powdered  lead  nitrate,  an  ordinary 
gauze  dressing  being  applied  over  this.  When  ulceration  has  under- 
mined the  nail,  the  latter  should  be  trimmed  away  sufficiently  to 
allow  thorough  local  treatment  to  be  apphed  to  the  entire  diseased 
surface.  Iodoform  and  aristol  are  both  useful  appKcations,  but  only 
when  they  are  brought  in  direct  contact  with  the  ulcer.  When  cica- 
trization has  taken  place,  careful  strapping  with  thin  strips  of  resin 
adhesive  plaster,  repeated  daily,  will  encourage  the  formation  of  a 
symmetrical  nail. 

SYPHILITIC   LESIONS   OF   THE   MUCOUS   MEMBRANE. 

The  mucous  membrane  manifestations  of  syphilis  correspond  in 
pathology  and  general  features  with  those  appearing  on  the  skin,  the 
difference  depending  upon  increased  vascularity,  diminished  resist- 
ance to  extension  and  ulceration  on  the  part  of  the  surrounding 
macerated  mucous  membrane,  and  a  greater  or  less  degree  of  irrita- 
tion incident  to  secretions  which  are  constantly  brought  in  contact 
with  the  lesions. 


390  GENITO-UKINAKY  DISEASES  AND  SYPHILIS. 

Erythematous  Syphilide. — This  attacks  the  throat,  the  vagina, 
the  urethra,  the  glans  penis,  and  the  inner  surface  of  the  foreskin.  It 
may  develop  on  any  mucous  surface  of  the  respiratory,  digestive,  or 
genito-urinary  tract.  As  in  the  case  of  the  corresponding  skin  erup- 
tion, the  lesions  first  appear  as  discrete  spots  ;  these  become  confluent 
in  a  few  hours,  exhibiting  then  a  somewhat  sharply  circumscribed 
circinate  margin. 

The  mucous  membrane  of  the  throat  is  most  frequently  attacked, 
the  patient  suffering  from  syphilitic  angina,  which  may  assume  the 
acute  or  the  chronic  form.  The  hypersemia  and  oedema  involve  the 
pharynx,  tonsils,  half-arches,  and  soft  palate,  but  rarely  extend  to 
the  hard  palate,  though  the  latter  may  exhibit  discrete  macules. 

So  quickly  does  the  macular  eruption  of  the  mucous  membrane 
become  confluent  that,  Avhen  first  observed,  the  lesions  depending 
upon  their  location  closely  simulate  simple  sore  throat,  balanoposthitis, 
vaginitis,  or  urethritis.  It  is  most  important  to  recognize  the  syphi- 
litic nature  of  such  lesions,  since  they  may  appear  before  other  more 
characteristic  secondary  symptoms,  or  as  the  only  manifestation  of 
the  disease,  and  since  their  discharges  are  contagious. 

Diagnosis. — The  diagnosis  will  usually  be  founded  on  associated 
signs  or  symptoms  of  syphilis,  and  on  the  absence  of  a  cause  for 
simple  inflammation.  There  is  nothing  typical  or  characteristic  in 
the  local  appearance. 

Papular  Syphilide. — The  papular  eruption  upon  the  mucous 
membranes  may  appear  as  a  denudation  or  erosion,  as  a  circum- 
scribed diphtheroid  patch,  as  a  vegetating  papule,  as  a  superficial 
ulceration,  or  as  a  scaly  patch.  These  lesions  are  more  prone  to  re- 
cur than  the  homologous  lesions  of  the  skin,  and  are  more  obstinate 
to  treatment. 

They  are  exactly  simulated  by  the  papular  syphihde,  as  it  de- 
velops about  the  mucous  orifices,  on  the  scrotum,  beneath  the 
breasts,  or  in  any  region  where  heat,  moisture,  and  friction  modify 
the  eruption. 

All  forms  of  papular  eruption  are  classed  under  the  general 
heading  of  mucous  patches,  though  this  term  is  often  limited  to 
lesions  covered  by  a  gray-white  pseudo-membrane  or  to  the  later 
scaly  eruption  of  the  mucous  membrane. 

The  papular  erosion  appears  in  the  form  of  oval  or  rounded,  small 
or  large,  infiltrated  patches,  exhibiting  a  raw-ham  color,  denuded  of 
epithelial  covering,  and  showing  a  smooth,  glistening  surface.  It  is 
usually  placed  on  the  dorsum  of  the  tongue,  and  associated  with  it 
are  found  fissures  of  the  borders  of  the  organ,  and  mucous  patches. 


CONSTITUTIONAL   SYPHILIS.  891 

It  is  particularly  common  in  inveterate  smokers  and  hard  drinkers; 
and,  indeed,  this  is  true  of  all  the  mouth  lesions  of  syphilis. 

The  diphtheroid  papule,  the  commonest  form  of  the  mucous  patch, 
appears  as  a  small  or  large,  discrete  or  confluent  papule  covered  with 
a  tightly  adherent,  gray-white  pseudo-membrane,  which  ion  being  re- 
moved leaves  a  bleeding  surface.  The  diphtheroid  membrane  is  but 
little  elevated  above  the  level  of  the  surrounding  healthy  surface.  It 
is  somewhat  sharply  deflned  from  the  latter  by  a  narrow  hypersemic 
zone  often  exhibiting  the  dusky-red  coloration  of  syphilitic  lesions. 
There  may  be  central  absorption  of  the  infiltrate  and  healing  in  this 
portion  of  the  lesion  while  there  is  extension  at  the  periphery,  thus 
producing  ring-like  and  serpiginous  figures. 

This  form  of  mucous  patch  is  generally  found  on  the  mucous 
membrane  of  the  cheeks  and  lips  and  at  the  angles  of  the  mouth, 
where  it  becomes  fissured,  on  the  sides,  under  surface,  and  fraenum 
of  the  tongue,  on  the  gums,  and  on  the  soft  palate,  half-arches,  and 
tonsils. 

The  lesions  may  be  attended  with  Assuring,  with  superficial  ulcera- 
tion, and,  when  situated  on  the  tonsils,  with  deep  and  destructive 
ulceration.  Under  these  circumstances  they  may  become  extremely 
sensitive,  interfering  with  eating  or  drinking,  or  even  speaking,  and 
occasioning  an  annoying  flow  of  saliva. 

When  the  mucous  patch  is  undergoing  involution,  either  under 
the  influence  of  constitutional  or  local  treatment  or  spontaneously, 
and  loses  its  diphtheroid  covering,  it  presents  the  appearance  of  a 
papular  erosion,  then  heals  over,  exhibiting  a  temporary  pigmentation. 

When  these  chphtheroid  papules  become  distinctly  inflammatory 
in  type  they  may  react  upon  the  anatomically  related  lymphatic  glands, 
producing  enlargement,  and  in  some  cases,  from  mixed  infection, 
suppuration. 

The  vegetating  papule  exhibits  the  tendency  towards  local  hyper- 
trophy which  is  sometimes  a  marked  feature  of  syphilitic  lesions. 

The  infiltration  common  to  all  the  lesions  of  syphilis  is  in  the  case 
of  this  manifestation  of  the  disease  particularly  well  marked ;  in  addi- 
tion, the  papillae  of  the  mucous  membrane  are  greatly  hypertrophied  ; 
there  results  a  raised  lesion,  which  is  in  reality  an  infiltrated  papil- 
loma, varying  in  size  from  that  of  a  split  pea  to  that  of  a  half-walnut. 

The  surface  of  this  lesion  may  he  covered  with  a  gray-white  false 
membrane,  or  may  present  an  eroded  appearance.  The  lesions  have 
a  marked  tendency  towards  peripheral  extension,  and  when  several 
are  placed  near  together  these  are  likely  to  become  confluent. 

The  vegetating  papule  is  comparatively  rare  upon  mucous  mem- 


892  GEXITO-UKIXAET   DISEASES   AND   SYPHILIS. 

branes.  It  is  commonly  encountered  about  the  vulva  in  women  and 
in  the  anal  region  in  men.  From  infiltration  the  surface  upon  which 
these  lesions  are  placed  loses  its  elasticity,  so  that  rhagades  or  fissures- 
are  hkely  to  occur. 

Superficial  ulcerations  are  frequently  associated  with  the  vege- 
tating papules ;  these  represent  infiltration  in  which  there  has  been 
destruction  of  tissue,  a  distinct,  punched-out,  freely  secreting  ulcer 
occupying  the  site  of  a  lesion  which  in  its  early  stages  presented  the 
appearance  of  a  vegetating  papule.  This  ulcerating  lesion  is  more  fre- 
quently encountered  upon  the  skin  than  upon  the  mucous  membranes. 

Papulo-Squamous  Syphilide. — The  scaly  patches  (mucous  psoriasis, 
opaline  plaques)  rarely  appear  in  the  course  of  constitutional  syphilis. 
They  are  rounded  or  irregularly  shaped,  flat,  smooth,  bluish-white 
patches,  such  as  would  result  from  lightly  brushing  a  surface  with 
strong  silver  nitrate  solution.  The  white  coloration  is  due  to  changes- 
in  the  epithehum,  consequent  on  chronic  irritation  and  inflammatory 
infiltration.  The  normal  columnar  cells  are  replaced  by  squamous 
epithelium  arranged  in  many  layers,  producing  a  species  of  cornifi- 
cation  identical  with  that  described  when  considering  the  pathological 
changes  incident  to  chronic  urethritis  ;  as  the  thickening  is  greatest  at 
the  centre  and  becomes  less  marked  towards  the  periphery,  so  the 
color  shades  into  that  of  the  surrounding  mucous  membrane.  The 
thickened  epithelium  is  itself  adherent  to  the  underlying  surface,, 
but  its  removal  does  not  occasion  bleeding.  Frequently  the  central 
thickened  epithelium  exfoliates,  while  the  lesion  extends  peripherally, 
leaving  either  a  surface  of  hypertrophied  and  infiltrated  papillae,  a 
distinct  erosion,  or  even  healthy  mucous  membrane  surrounded  by  a 
white  ring  of  epithehum.  From  confluence  of  such  patches  curious 
markings  are  sometimes  observed  on  the  tongue. 

This  lesion  is  most  frequently  observed  on  the  buccal  mucous 
membrane,  along  the  alignment  of  the  upper  and  the  lower  teeth 
when  the  jaw  is  closed,  the  patches  usually  being  more  or  less  con- 
fluent. It  also  develops  on  the  inner  surface  of  the  lips,  and  on  the 
dorsum,  sides,  and  under  surface  of  the  tongue. 

As  with  other  lesions  of  syphihs,  there  is  little  pain  excited  by 
white  scaly  patches,  except  where  they  are  associated  with  fissures- 
and  ulcerations. 

Unlike  the  other  forms  of  papular  eruption,  the  scaly  patch  usually 
denotes  a  late  stage  of  the  disease.  It  may  develop  at  any  time  in  the 
late  secondary  and  tertiary  periods,  and  is  usually  exceedingly  obsti- 
nate to  treatment. 

Gummata  may  develop  in  tertiary  syphilis,  both  in  the  mucous 


CONSTITUTIONAL   SYPHILIS.  893- 

membrane  and  in  the  submucous  connective  tissue.  Tliey  may  take 
the  form  of  diffuse  infiltrations  or  of  circumscribed  tumors. 

The  mucous  gummata  appear  as  small  tumors,  which  rarely  reach 
the  size  of  a  pea  before  breaking  down,  forming  punched-out,  un- 
healthy ulcers,  about  the  circumference  of  which  is  often  to  be  noted 
a  raw-ham-colored  infiltrate. 

These  lesions  pecuUarly  affect  the  hard  and  the  soft  palate,  and 
often  exhibit  a  serpiginous  grouping  and  a  slow  extension  in  one 
direction  while  cicatrization  is  taking  place  in  the  ulcer  which  first 
developed. 

The  submucous  gummata  form  larger  tumors  before  breaking 
down.  They  exhibit,  however,  a  marked  tendency  to  soften  towards 
the  surface,  producing  deep,  punched-out  ulcers  with  infiltrated 
borders. 

The  ulcerating  gummata  are  responsible  for  the  stenosing  cica- 
trices which  may  develop  in  nearly  any  portion  of  the  alimentary 
canal,  though  they  are  most  frecjuently  recognized  in  the  oesophagus 
and  the  rectum. 

Diagnosis  of  Mucous  Syphilides. — To  distinguish  the  erosive  and 
diphtheroid  forms  of  the  mucous  patch  from  the  ulcers  of  simple 
aphthae  is,  from  the  appearance  of  the  lesions  alone,  impossible. 
Aphthae,  however,  are  generally  more  tender,  more  liable  to  be  dis- 
crete, develop  in  a  day  or  two,  run  a  rapid  course,  and,  either  with 
or  without  treatment,  are  well  in  a  few  days. 

The  chfficulty  in  diagnosis  is  made  much  greater  by  the  fact  that 
it  is  especially  in  syphilitics  that  aphthous  spots  are  liable  to  develop. 
Fournier  describes  a  recurrent  herpes  which  attacks  the  oral  mucous 
membrane  of  syphilitics,  producing  small  erosions  which  exactly  re- 
semble mucous  patches.  This  eruption  develops  some  years  after  a 
methodical  course  of  treatment  has  apparently  eradicated  the  syphi- 
litic taint.  Specific  treatment  is  absolutely  without  effect,  the  erosions 
disappearing  spontaneously  in  a  few  days  and  recurring  at  irregular 
intervals. 

In  making  a  differential  diagnosis  between  the  erosive  and  diph- 
theroid forms  of  mucous  patches,  aphthae,  and  herpetic  lesions,  the 
history  of  the  case,  the  presence  of  other  signs  of  syphilis,  and  the 
effect  of  constitutional  treatment  would  all  lead  to  a  correct  decision. 

The  scaly  paiches  (mucous  psoriasis,  opaline  plac|ues)  must  be 
chstinguished  from  non-specific  leucopJahia  (hyperkeratosis).  The 
latter  sometimes  develops  acutely,  particularly  in  women  and  chil- 
dren. The  lesions  change  in  form  and  distribution  with  such  rapidity 
that  there  is  little  danger  of  considering  the  disease  specific. 


894  GEI^flTO-UKIN^AEY   DISEASES   AND   SYPHILIS. 

The  chronic  form  of  leiicoplakia  may  be  so  closely  smiulated  by 
the  syphilitic  lesion  that  a  differential  diagnosis  will  be  a  matter  of 
great  difficulty. 

The  idiopathic  leucoplakia — i.e.,  that  of  non-syphilitic  drinkers 
and  smokers — is  even  slower  in  development  than  the  specific  lesion; 
the  white  color  and  the  heaping  up  of  epithelial  cells  are  more 
marked  and  irregular :  there  is  not  the  same  tendency  towards  central 
exfoliation,  as  the  lesion  extends  peripherally, — hence  the  resultant 
ring-like  configuration  is  less  common.  In  leucoplakia  the  lesions  are 
more  often  found  on  the  tongue  and  the  lower  lip,  subjective  sensa- 
tions are  said  to  be  more  marked,  and  specific  treatment  is  absolutely 
without  avail  in  effecting  a  cure.  - 

The  points  of  difference  by  which  ulcerating  gummatous  lesions 
of  the  mucous  membrane  can  be  distinguished  from  the  tubercular 
and  malignant  infiltrations  will  be  considered  when  discussing  the 
subject  of  gummata  in  special  regions. 

Treatment. — The  treatment  of  mucous  syphilides  is  constitutional 
and  local,  topical  apphcations  being  much  more  distinctly  indicated 
than  is  the  case  with  skin  lesions,  except  when  the  latter  assume  the 
form  of  mucous  patches. 

Syphilis  of  the  Tongue. — Chancre  is  rare  upon  the  tongue,  but 
when  present  is  usually  at  or  near  the  tip  of  this  organ.  (Du  Castel.) 
It  is  of  the  erosive  type,  and  presents  no  peculiarities  of  development. 

Roseola  is  rare  and  ephemeral.  It  appears  in  the  form  of  shght 
desc{uamative  stains. 

Mucous  patches  are  of  the  erosive,  diphtheroid,  and  vegetating 
type  ;  the  last  variety  is  rare.  When  mucous  patches  are  numerous 
and  confluent  there  is  general  swelling  of  the  tongue,  the  latter  show- 
ing on  its  borders  the  imprint  of  the  teeth.  Mucous  patches  placed 
along  the  sides  of  the  tongue — a  favorite  seat — often  exhibit  more  or 
less  Assuring,  in  which  case  they  may  be  accompanied  by  much  pain. 

The  ulcerations  of  secondary  sjqDhilis  are  usually  small  and  super- 
ficial, and  are  attended  with  few  subjective  symptoms ;  even  should 
they  become  deep,  inflammatory  symptoms  are  not  marked. 

Smooth  patches  (Fournier)  are  not  very  perceptible  till  the  tongue 
is  dried  by  a  towel  or  some  absorbing  fabric.  They  then  appear  as 
smooth,  shining  surfaces  from  which  the  epithelium  has  entirely 
disappeared.  There  is  no  sign  of  erosion.  The  lesions  are  circular 
in  form,  and  are  grouped  in  circles  or  segments  of  circles. 

This  form  of  desc(uamating  glossitis  is  found  in  both  the  secondary 
and  the  tertiary  period  of  syphihs.  It  at  times  precedes  the  forma- 
tion of  syphilitic  leucoplakia. 


CONSTITUTIONAL   SYPHILIS.  895 

Scaly  patches  (syphilitic  leucoplakia)  are  hardly  ever  seen  except 
^>n  the  tongues  of  habitual  smokers  and  drinkers.  They  exhibit  the 
gray-white,  circular,  circinate,  or  annular  stains  already  described, 
and  occasion  no  symptoms  unless  extensive,  when  they  may  be 
associated  with  some  stiffness  of  the  tongue  interfering  with  articu- 
lation ;  there  may  also  be  tingling  and  a  feeling  of  numbness.  The 
importance  of  these  lesions  Hes  in  the  fact  that  they  are  prone  to 
become  cancerous. 

The  strictly  tertiary  lesions  of  the  tongue  may  appear  either  in 
the  form  of  a  diffuse  gummatous  infiltration  (sclerous  glossitis)  or 
as  circumscribed  gummata.  These  gummatous  lesions  develop  on 
the  tongue  more  frequently  than  in  any  other  portion  of  the  mouth. 
They  are  much  more  commonly  observed  in  men  than  in  women, 
probably  because  of  the  chronic  irritation  produced  by  the  use  of 
tobacco  and  alcohol. 

Diffuse  gummatous  infiltration,  or  syphilitic  sclerous  glossitis,  is 
really  a  form  of  chronic  myositis.  It  may  be  either  superficial  or 
deep,  and  may  involve  part  of  the  tongue  or  the  whole  organ. 

The  affection  begins  as  a  slowly  progressive,  hard  swelhng,  usually 
involving  but  one  side  of  the  tongue,  and  producing  marked  asymme- 
try. When  both  sides  are  enlarged  there  may  be  ^o  niLich  swelling 
that  the  patient  will  not  be  able  to  close  his  mouth.  This  condition 
develops  with  comparatively  slight  symptoms.  There  is  no  pain,  the 
patient  complaining  only  of  a  feehng  of  weight  and  stiffness,  making 
articulation  somewhat  labored.  After  weeks,  or  perhaps  months, 
the  swelling  gradually  subsides  coincidently  with  the  occurrence  of 
atrophic  changes,  which  produce  even  greater  stiffening  and  indura- 
tion than  were  present  in  the  early  stages  of  the  affection. 

Examination  of  the  surface  of  the  tongue  then  shows  irregular 
lobulations,  with  marked  alteration  of  the  mucous  membrane.  There 
are  often  smooth,  red  patches,  due  to  exfoliation  of  epithelium,  or 
areas  of  greatly  thickened  epitheham,  which  may  present  the  typical 
white  appearance  of  syphilitic  leucoplakia. 

From  mechanical  irritation  by  the  teeth,  cracks,  erosions,  and 
ulcers  are  often  formed. 

Circumscribed  gumma,  or  gummatous  glossitis,  may  be  superficial  or 
deep, — that  is,  it  may  involve  the  mucous  or  the  submucous  tissues, 
or  may  start  in  the  substance  of  the  muscles. 

The  superficial  gummata  appear  as  small,  round,  hard  nodules  of 
the  mucous  membrane  or  submucous  connective  tissue.  They  vary 
in  size  from  that  of  a  grape-seed  to  that  of  a  cherry.  They  occasion 
little  or  no  pain,  and  if  not  treated  by  internal  medication  usually 


g96  GENITO-URINAEY   DISEASES  AND   SYPHILIS. 

soften  and  ulcerate,  forming  punched-out,  indurated,  undermined, 
unhealthy  ulcers. 

When  these  gummatous  ulcers  are  multiple  and  confluent,  and 
particularly  when  they  are  phagedenic  in  type,  they  may  destroy  the 
greater  part  of  the  tongue,  and  may  threaten  life  from  backward 
extension  of  the  inflammation  and  sudden  oedema  of  the  glottis. 

The  deep  or  muscular  gummata  begin  as  hard,  painless  tumors, 
firmly  adherent  to  the  surrounding  tissues.  They  are  nearly  always 
j)laced  on  the  dorsum  of  the  tongue.  They  occasion  little  or  no 
pain,  causing  inconvenience  only  from  the  limitation  of  motion. 
They  grow  slowly,  usually  not  softening  and  ulcerating  for  two  or 
three  months.  They  vary  in  size  from  that  of  a  cherry  to  that  of  a 
lemon.  When  they  finally  ulcerate,  deep,  punched-out,  indolent, 
indurated  ulcers  are  found. 

The  ulcerating  gummata  of  the  tongue,  even  though  deep  and 
confluent,  excite  little  pain  except  on  motion,  and,  indeed,  all  the 
symptoms  of  acute  inflammation  are  absent.  On  the  healing  of  the 
ulceration  there  results  a  scar,  which  may  be  both  disabling  and 
deforming. 

Diagnosis. — The  diagnosis  of  syphilitic  affections  of  the  tongue  is 
made  upon  the  general  principles  discussed  when  treating  of  syphihs 
of  the  mucous  membranes. 

It  is  particularly  on  the  tongue  that  the  lesions  of  recurrent  herpes 
are  manifested,  and  it  is  here  that  they  are  most  frequently  taken  for 
mucous  patches  or  other  lesions  of  active  syphilis. 

Among  other  affections  simulating  syphihs  of  the  tongue,  such  as 
ichthyosis  and  superficial  glossitis,  is  a  disease  of  infancy  variously 
characterized  as  erratic  rash,  circinated  herpes,  or  geographical 
annulus  migrans.  The  tongue  becomes  covered  with  concentric  rings 
formed  by  small,  red  patches.  The  senses  of  taste  and  touch  are 
normal ;  sometimes,  however,  they  may  be  slightly  hyperacute.  This 
disease  may  easily  be  mistaken  for  mucous  patches  or  for  congenital 
syphilis. 

Ulcerating  gummata  of  the  tongue  may  readily  be  confounded 
with  tubercular  or  cancerous  lesions. 

Tubercular  lesions  are  usually  single,  and  are  seated  at  or  near  the 
tip  or  on  the  dorsal  surface  of  the  organ.  They  begin  as  cracks  or 
fissures,  attended  by  swehing,  and  slowly  form  shallow,  jagged,  pain- 
ful ulcerations,  with  non-indurated  borders,  which  are  often  sur- 
rounded by  minute,  pale-yellow  points  with  opaque  centres.  These 
are  tubercular  granulations  undergoing  caseous  degeneration.  They 
are  frequently  thrown  off  by  ulceration,  and  are  never  seen  in  syph- 


CONSTITUTIONAL   SYPHILIS. 


897 


ilis.  Tubercular  glossitis  rarely  appears  as  an  isolated  symptom  of 
the  diathesis,  the  larynx,  lungs,  or  other  organs  generally  showing 
involvement.  The  tubercle  bacillus  may  be  found  on  microscopic 
examination,  or  may  be  cultivated  by  inoculation  of  guinea-pigs.  The 
lesion  is  slow  in  its  course,  and  is  not  favorably  influenced  by  specific 
treatment. 

The  gumma  begins  as  a  single  submucous  or  muscular  mass,  open- 
ing after  a  time  by  a  narrow  passage,  ulcerating  and  discharging  like 
a  furuncle,  having  a  sloughing  indurated  base. 

Carcinoma  is  generally  found  at  the  borders  of  the  tongue,  as  a 
consequence  of  long-standing  irritation.  It  begins  as  an  erosion  or 
ulcer,  which  subsequently  becomes  indurated,  may  show  about  its 
borders  epithelial  pegs,  is  shortly  followed  by  glandular  involvement, 
is  steadily  progressive  and  somewhat  rapid  in  its  course,  and  is  fre- 
quently very  painful.  The  diagnosis  may  be  obscured,  indeed  ren- 
dered impossible,  by  the  fact  that  carcinoma  and  gumma  may  develop 
side  by  side. 

The  points  of  difference  between  carcinoma  and  ulcerating  gumma 
are  embodied  in  the  following  table  (Fournier). 


Epithelioma. 

Period  of  Occurrence. — Chiefly  after  the 
fiftieth  year. 

History. — Often  cancerous,  and  preceded 
by  lingual  psoriasis. 

Location. — Often  on  the  lateral  and 
under  surface  of  the  tongue ;  uni- 
lateral. 

Number. — Single. 

Beginning. — An  irregular,  indurated, 
superficial  ulceration,  which  extends 
rapidly.  Marked  induration  follows 
ulceration. 

Appearance. — Elevated,  irregular,  evert- 
ed borders  ;  ulcerating  surfaces  bleed- 
ing rapidly  on  mechanical  interfer- 
ence.    No  cavity  resembling  abscess. 

Discharge. — Profuse,  offensive,  irri- 
tating. 

Symptoms. — Lancinating  pain  often  dart- 
ing towards  the  ear  ;  great  functional 
disturbance  (deglutition,  mastication, 
speech,  etc.).     General  cachexia. 

Lyynphatic  Involvement. — Submaxillary 
lymphatic  glands  progressively  en- 
larged and  densely  indurated. 


Gumma. 
Period  of  Occurrence. — Earlier  in  life. 

History. — Not  cancerous.  Not  preceded 
by  lingual  psoriasis. 

Location. — Always  on  the  dorsal  sur- 
face ;  may  be  bilateral. 

Number. — May  be  multiple. 

Beginning. — A  thick,  rounded  indura- 
tion, opening  like  a  furuncle,  and 
leaving  a  deep  hollow  ulcer.  Marked 
induration  precedes  ulceration. 

Appearance. — Punched-out,  sharply  de- 
fined edges ;  sloughing  surface,  not 
easily  excited  to  bleeding.  Excava- 
tion like  an  abscess-cavity. 

Discharge. — Moderate,  not  very  offen- 
sive. 

Symptoms. — Nearly  painless  ;  only  slight 
functional  disturbance.     No  cachexia. 


Lymphatic  Involvement. — None,  or  slight 
swelling  and  tenderness. 


57 


898  GENITO-UKINART  DISEASES   AND  SYPHILIS. 

Epithelioma.  Oumma. 

Therapeutic      Test. — Specific    treatment      Therapeutic     Test. — Specific     treatment 

useless  or  harmful.  curative. 

Microscopic  Examination. — Pearly  bodies.     Microscopic     Examination. — Embryonal 

cells   in  various   stages   of  granular 
degeneration. 

Syphilis  of  the  G-ums. — Aside  from  the  pyorrhoea  induced  by 
medication,  and  arising  from  deranged  digestion  and  secondary  lesions 
in  the  mouth,  occasionally  there  is  noted  in  tertiary  syphilis  a  distinct 
pyorrhoea  alveolaris,  signifying  syphilitic  disease  of  the  bone.  This, 
unlike  the  pyorrhoea  of  medication,  is  cured  by  rapidly  pushing  the 
treatment. 

Syphilis  of  the  Palate. — The  soft  palate,  uvula,  and  half-arches 
usually  show  the  diffuse  or  macular  erythema  of  the  early  secondary 
specific  anginas  ;  mucous  patches  are  also  frequently  found  attacking 
these  structures. 

GuMMATA  OF  THE  HARD  PALATE  usually  begin  in  the  periosteum,  and 
are  found  in  or  near  the  middle  line  forming  elevated,  sometimes 
painful,  usually  multiple,  elastic  swellings,  which  shortly  soften  and 
ulcerate,  exposing  the  bone,  resulting  in  necrosis  of  the  latter  and 
in  direct  communication  between  the  cavities  of  the  nose  and  the 
mouth. 

When  these  gummata  begin  on  the  oral  surface  of  the  palate 
they  usually  can  be  detected  in  time  to  prevent  perforation. 

When,  as  is  more  commonly  the  case,  they  develop  on  the  nasal 
side  of  the  palate,  there  is  often  no  suspicion  of  trouble  till  a  dusky, 
oedematous,  circumscribed  swelling  appears  on  the  roof  of  the  mouth, 
which  in  a  very  few  days  shows  an  opening  into  the  cavity  of  the 
nose.  This  opening  represents  the  small  end  of  a  funnel-shaped 
ulcer,  which  on  examination  from  the  nasal  side  of  the  palate  may 
be  found  to  be  of  considerable  size. 

The  gummata  may  be  multiple,  and  by  confluence  may  produce 
large  openings  in  both  the  hard  and  the  soft  palate.  They  sometimes 
develop  very  rapidly,  destroying  the  uvula  and  the  greater  part  of  the 
soft  palate  in  a  few  days.  When  these  ulcerating  gummata  heal  there 
may  result  great  cicatricial  deformity,  and  perforations  which  can  be 
closed  only  by  plastic  operation. 

Gummata  of  the  soft  palate  develop  slowly,  without  pain  or  dis- 
comfort on  the  part  of  the  patient.  There  may  be  a  general  nodular 
infiltration,  or  but  a  single  gumma  at  one  point.  Ordinarily  there  is  a 
diffuse  infiltrate,  which  can  be  distinctly  felt  on  palpation.  If  this 
primarily  involves  the  pharyngeal  wall  of  the  palate,  the  only  appre- 


CONSTITUTIONAL    SYPHILIS.  899 

ciable  symptoms  will  be  stiffness  and  immobility,  which  are  diagnostic 
signs  of  considerable  value.  These  signs  can  be  ehcited  by  exposing 
the  pharynx  while  the  throat  is  being  examined  and  instructing  the 
patient  to  utter  some  sounds  requiring  the  assistance  of  the  soft  palate 
for  their  production.  When  immobility  is  thus  detected  and  is  found 
to  be  associated  with  nodular  induration,  the  diagnosis  of  gumma 
can  be  made  at  once.  If  the  anterior  wall  is  involved,  the  dark  red, 
oedematous,  sometimes  nodular  mucous  membrane  will  suggest  the 
nature  of  the  affection.  This  diffuse  infiltration  is  prone  to  ulcerate, 
destroying  a  part  or  the  whole  of  the  palate  and  uvula.  The  inflam- 
matory process  is  not  limited  to  the  soft  palate,  often  extending  to  the 
anterior  and  posterior  half-arches.  The  cicatricial  processes  follow- 
ing ulceration  may  produce  great  deformity.  The  soft  palate  may  be 
partly  or  totally  wanting,  or  may  be  adherent  to  the  posterior  pharyn- 
geal wall,  partly  or  completely  separating  the  naso-pharynx  from  the 
pharynx  ;  though  not  adherent,  it  may  be  stretched  tightly  across  the 
naso-pharynx,  having  entirely  lost  its  suppleness  and  mobility. 

Circumscribed  gummata  of  the  soft  palate  may  be  single  or  mul- 
tiple ;  they  are  commonly  placed  on  the  oral  surface.  They  usually 
ulcerate  if  untreated,  often  causing  perforation.  Mauriac  has  called 
attention  to  the  fact  that  gummatous  ulceration  involving  the  velum, 
the  tonsil,  the  half-arches,  and  the  lateral  wall  of  the  pharynx,  and 
opening  up  the  Eustachian  tube,  often  begins  in  the  recess  formed  by 
the  juncture  of  the  anterior  and  posterior  half-arches  and  the  upper 
surface  of  the  tonsil.  This  ulceration  may  be  extensive  and  rapid, 
spreading  wide  of  the  tonsil  and  palato-pharyngeal  fold  and  even 
eroding  the  carotid  artery. 

Syphilis  of  the  Pharynx. — Gummata  of  the  pharynx  may  be 
submucous  or  subperiosteal.  They  usually  appear  as  one  or  more 
hard,  painless  swellings  of  the  posterior  wall.  Softening  and  ulcer- 
ation follow,  resulting  in  deep,  punched-out,  indurated  ulcers.  When 
gummatous  ulceration  involves  both  the  soft  palate  and  the  pharynx, 
adhesions  may  take  place  in  the  process  of  healing,  which  entirely 
shut  off  the  nasal  cavity  from  the  mouth ;  or  by  involvement  of  the 
half-arches  and  tonsils  the  pharyngeal  communications  between  the 
mouth  and  the  larynx  may  be  greatly  narrowed. 

The  late  ulcerating  lesions  of  the  soft  palate  and  the  pharynx  are 
often  accompanied  during  their  evolution  by  pain,  disability,  and 
interference  with  hearing,  and  may  be  followed  by  intractable  catarrh 
of  the  naso-pharynx  incident  to  the  deformity  following  cicatrization. 

As  a  result  of  this  cicatricial  contraction  the  voice  may  be  mark- 
edly altered ;    deglutition  may  be  difficult ;    or  the  isthmus  of  the 


900  GENITO-UKINAEY  DISEASES  AND   SYPHILIS. 

fauces  may  be  so  narrowed  that  there  will  be  marked  obstruction  to 
the  entrance  o?  air.  Such  cicatrices  are  almost  pathognomonic  of 
syphilitic  ulceration. 

Gummata  of  the  pharynx  are  generally  associated  with  tertiary 
infiltrations  of  the  nasal  or  the  oral  mucous  membrane.  The  throat 
often  presents  an  irregularly  ulcerated  appearance,  and  exceptionally 
extremely  chronic,  distinct,  punched-out,  typical  gummatous  ulcers 
develop,  which,  if  untreated,  may  extend  to  the  underlying  bone. 

The  Tonsils. — Gummata  are  very  rarely  observed  upon  the  lips 
or  cheeks,  and  are  comparatively  rare  upon  the  tonsils. 

The  ulcerating  lesion  commonly  observed  on  the  tonsil  and  often 
considered  gummatous  is  in  reahty  a  vegetating  papule,  which  ulcer- 
ates, spreads  somewhat  rapidly,  and  may  assume  a  diphtheroid  or 
even  a  phagedenic  type.  The  ulceration  is  much  more  superficial 
than  is  that  of  gumma. 

Gum5L4lTOus  tonsillitis  is  characterized  by  painless,  hard  enlarge- 
ment, with  little  functional  disturbance,  except  perhaps  some  inter- 
ference with  hearing.  The  mucous  membrane,  at  first  stretched 
tightly  over  the  swelhng,  becomes  somewhat  less  tense  as  softening 
takes  place,  and  finally  ruptures.  Then  result  one  or  more  punched- 
out  ulcers  with  indurated  borders  and  gray  sloughing  surfaces.  These 
may  become  confluent,  involving  the  anterior  half-arches,  and  may 
produce  marked  deformity  when  healing  takes  place.  Cicatricial  con- 
tractions resulting  from  these  gummata  may  cause  permanent  closure 
of  the  Eustachian  tube  and  interference  with  hearing. 

Subperiosteal  gummata,  resulting  in  caries  and  necrosis,  are  most 
frequently  observed  on  the  hard  palate,  the  alveolar  border  of  the 
upper  jaw  at  the  insertion  of  the  incisor  teeth,  and  the  posterior  wall 
of  the  pharynx. 

The  (Esophagus,  Stomach,  and  Intestines. — It  is  apparent 
from  a  few  reported  cases  and  from  many  autopsies  that  gummatous 
ulceration  may  occur  in  any  portion  of  the  alimentary  canal.  It  seems 
probable,  also,  that  the  mucous  membrane  of  this  tract  is  subject 
to  specific  general  or  local  inflammation  during  the  secondary  period 
of  the  disease.  Thus  the  s^miptoms  of  catarrhal  gastritis  or  gastro- 
enteritis which  are  so  frequently  associated  with  syphilitic  fever  or 
are  observed  before  or  during  the  outbreak  of  the  first  erythema  may 
be  due  to  the  direct  efl'ect  of  syphihs  upon  the  stomach  and  bowels. 
The  chronic  gastritis  often  associated  with  specific  lesions  of  the  liver 
or  spleen  may  also  represent  a  specific  infiltration,  since  it  is  favorably 
influenced  by  specific  treatment. 

The  (Esophagus. — The  superficial  lesions  of  early  syphilis  have  not 


CONSTITUTIONAL   SYPHILIS.  901 

been  recognized  in  the  oesophagus.  Deep  ulceration  extending  from 
the  pharynx  is  followed  by  stricture.  Infiltrating  gummata  devel- 
oping in  the  submucous  connective  tissue  commonly  ulcerate,  event- 
ually forming  incurable  strictures.  The  diagnosis  during  either  the 
ulcerating  or  the  cicatrizing  stage  of  the  lesion  is  dependent  abso- 
lutely on  the  finding  of  associated  signs  of  syphilis,  in  the  absence  of 
other  etiological  factors,  and  on  the  effect  of  vigorous  constitutional 
treatment.  This,  if  pushed  in  the  ulcerating  or  early  contracting 
stage,  should  produce  rapid  improvement  in  the  symptoms  of  oeso- 
phageal narrowing. 

The  Stomach. — In  addition  to  the  symptoms  of  acute  and  chronic 
catarrh,  those  of  gastric  ulcer  are  sometimes  noted.  This,  even 
though  occurring  in  a  syphilitic,  may  be  non-specific  in  nature,  or  it 
may  be  due  to  the  breaking  down  of  a  gumma.  In  the  latter  case  it 
is  likely  to  be  located  near  the  lesser  curvature  in  the  pyloric  region. 
The  symptoms  of  gastric  ulcer  of  syphilitic  origin  do  not  differ  from 
those  of  the  non-specific  ulcer.  The  diagnosis  must  be  founded  on 
a  therapeutic  test,  though  at  least  two  reported  cases  seem  to  show 
that  when  the  lesion  is  due  to  syphilis  the  pain  is  greatest  at  night. 

The  Intestines. — Except  the  beneficial  results  of  specific  treat- 
ment, there  is  no  feature  of  acute  or  chronic  syphilitic  enteritis  to 
distinguish  it  from  non-specific  catarrh. 

Ulceration  of  the  small  intestine  may  be  due  to  the  breaking 
down  either  of  a  gumma  or  of  the  lymph-glands  of  the  intestinal 
wall.  According  to  Rieder's  researches,  ulceration  of  the  bowel  is 
most  frequent  in  the  upper  portion  of  the  small  intestine.  The 
ulcers  are  multiple  and  grouped,  exhibit  the  characteristic  infiltration 
of  gummatous  ulcers,  and  are  late  tertiary  manifestations.  They 
involve  all  the  coats  of  the  bowel.  They  may  result  in  cicatricial 
stenosis. 

These  lesions  offer  no  clinical  features  peculiar  to  themselves. 
Their  nature  can  be  suspected  only  from  associated  symptoms  of 
syphilis. 

The  Rectum  and  Anus.— About  the  anal  aperture,  especially  in 
women,  mucous  patches  frequently  form.  These,  from  maceration 
and  from  the  irritation  incident  to  defecation,  are  prone  to  ulcerate, 
forming  rhagades  and  fissures,  which,  by  extending  in  depth,  may  in- 
volve the  tissues  of  the  ischio-rectal  space,  forming  deep  ulcers  or 
resulting  in  fistulae.  It  is  important  to  bear  in  mind  that  such  lesions 
may  occur  in  the  secondary  stage  of  syphilis. 

Gummata  may  develop  on  or  beneath  the  mucous  membrane  of 
the  anus  and  rectum,  or  in  the  surrounding  tissue  of  the  ischio-rectal 


902  GENITO-URINAEY   DISEASES   AFD   SYPHILIS. 

fossa.  Not  infrequently  they  assume  the  form  of  a  diffuse  infiltration, 
producing  rigidity  of  the  walls  of  the  bowel,  the  mucous  membrane 
remaining  quite  healthy.  This  may  be  followed,  if  untreated,  by  ulcer- 
ation or  interstitial  absorption,  in  either  case  resulting  in  stricture. 

Gummatous  ulceration  of  the  mucous  membrane  usually  begins 
just  about  the  internal  sphincter,  appearing- first  as  one  or  many 
small  nodules,  which  soften  and  break  down,  exhibiting  dark  gelat- 
inous cores.  They  finally  destroy  the  overlying  mucous  membrane, 
forming  ulcers,  which  become  confluent,  extend  in  area  and  depth, 
and  are  generally  accompanied  by  inflammatory  infiltration  of  the 
muscular  coat,  of  the  gut,  including  the  sphincter,  thus  producing  a 
narrowing  and  rigidity  distinctly  perceptible  to  the  examining  finger. 

The  ulceration  frequently  extends  upward,  other  gummata  form- 
ing and  ulcerating.  From  the  surface  and  border  of  these  ulcers  there 
may  be  an  exuberant  growth  of  granulations,  producing  fungous 
masses,  which  may  simulate  those  of  malignant  disease. 

Healing  is  accompanied  by  the  formation  of  scar-tissue,  which  in 
its  subsequent  contraction  often  produces  tight  strictures. 

The  perirectal  gummata  form  tumors  which  may  reach  consid- 
erable size  before  involving  and  breaking  through  the  mucous  mem- 
brane. As  a  result  of  the  entrance  of  the  bowel  contents  into  the 
cavities  of  these  gummata,  ischio-rectal  abscesses  are  formed,  ter- 
minating in  fistulse.  These  fistulse  may  be  vesico-vaginal,  are  often 
multiple,  and  in  some  cases  riddle  the  entire  perineum,  even  opening 
on  the  surface  of  the  thighs. 

The  strictures  resulting  from  cicatrization  of  recto-anal  ulceration 
are  much  more  frequent  in  women  than  in  men.  They  are  generally 
found  involving  the  lowest  portion  of  the  rectum,  and  are  often  asso- 
ciated with  vegetating  ulcers. 

Symptoms. — The  acute  or  chronic  proctitis  often  accompanying 
ulceration  and  gummata  of  the  rectum  occasions  a  muco-purulent 
discharge,  a  feeling  of  fulness  in  the  rectum,  and  usually  moderate 
tenesmus.  When  the  ulcers  become  fissured  and  deep,  burning 
pain,  tenesmus,  and  blood-stained  purulent  discharge  are  prominent 
symptoms.  The  passage  of  faeces  occasions  some  suffering,  and  is 
usually  followed  by  bleeding.  When  stricture-formation  is  fairly  well 
advanced  there  will  be  constipation  alternating  with  diarrhoea  and 
the  passage  of  ribbon-shaped  or  broken  stools. 

The  prognosis  must  be  guarded.  Even  if  active  specific  treatment 
cures  the  palpable  lesions,  there  sometimes  follows  faecal  inconti- 
nence, from  atrophy  of  the  sphincter  consequent  on  interstitial  myo- 
sitis.    tJlcers  about  the  rectum  are  always  extremely  slow  to  heal. 


CONSTITUTIONAL   SYPHILIS.  903 

Diagnosis. — The  lesions  of  syphilis  must  be  distinguished  from 
those  of  tuberculosis  or  cancer. 

The  tubercular  ulcer  is  found  in  persons  exhibiting  other  un- 
doubted lesions  of  tuberculosis. 

Cancer  almost  exactly  simulates  infiltrating  and  ulcerating  gum- 
mata.  It  is  more  prone  early  to  contract  tight  adhesions  to  neigh- 
boring parts,  and  is  usually  placed  higher  up  the  bowel  than  gumma. 
Excision  and  examination  of  a  portion  of  the  growth  would  establish 
its  pathology. 

Treatment. — In  addition  to  general  specific  medication,  the  ulcer- 
ating surfaces  must  be  treated  carefully.  When  ulcerations  are  slight 
and  superficial,  regulation  of  the  bowels  and  cleansing  injections 
repeated  night  and  morning  may  be  sufficient.  Deep  ulcers  may 
require  stretching  of  the  sphincter  followed  by  many  weeks  of  rest 
in  bed,  Avith  daily  topical  appHcations  suited  to  the  condition  of  the 
granulating  surface.  Strictures  can  be  benefited  only  by  dilatation  or 
operation. 


CHAPTER    XXV. 

SYPHILIS    OF    THE    NERVOUS    SYSTEM. OF    THE    EYE. OF    THE    EAR. OF    THE 

RESPIRATORY    TRACT. 

Cerebral  Syphilis. — There  is  no  nervous  symptom  caused  by 
syphilis  which  may  not  be  exactly  paralleled  by  a  symptom  found  in 
a  cerebropathy  from  another  cause ;  in  other  words,  there  are  no 
symptoms  pathognomonic  of  the  disease.  Caries  of  the  bones  of  the 
skull,  indirectly  implicating  the  brain,  produces  the  same  symptoms 
whether  the  caries  be  tubercular,  traumatic,  or  syphilitic,  and  pachy- 
meningitis, endarteritis,  and  cerebral  growths  cause  similar  symptoms 
regardless  of  their  etiology. 

Etiology. — A  nervous  temperament  seems  to  predispose  to  the 
development  of  brain-lesions,  though  from  this  it  must  not  be  under- 
stood that  brain-workers  are  more  prone  to  suffer  from  this  form  of 
the  disease  than  are  others.  The  conditions  which  certainly  predis- 
pose to  the  development  of  brain-symptoms  during  the  course  of 
syphiKs  are  absence  of  a  sufficiently  long  and  thorough  course  of 
specific  treatment  during  the  secondary  and  the  early  tertiary  period 
of  the  disease,  alcoholism,  or  hereditary  neurosis.  The  rheumatic 
diathesis,  traumatism,  prolonged  worry  or  anxiety,  and  exposure  to 
heat  are  also  held  to  favor  the  same  result. 

In  the  large  majority  of  cases  in  which  syphihs  attacks  the  nervous 
system,  it  does  so  in  the  absence  of  any  obviously  sufficient  cause, 
and  "  simply,"  as  Mauriac  says,  "  because,  forsooth,  it  pleases  it  to 
do  so." 

Mauriac  and  Broadbent  among  others  have  observed  that  in  cases 
of  cerebral  syphilis  the  primary  lesion  and  the  early  manifestations 
are  more  than  likely  to  have  been  quite  insignificant ;  no  positive 
conclusion,  however,  can  be  based  upon  this  observation,  because  no 
one  would  maintain  the  truth  of  its  converse, — viz.,  that  because  the 
secondary  lesions  or  manifestations  were  severe,  no  invasion  of  the 
nervous  system  would  follow.  The  probable  reason  why  syphilis 
attacks  the  nervous  system  after  a  light  secondary  stage  is  that,  on  ac- 
count of  its  mildness,  a  sufficiently  vigorous  and  prolonged  mercurial 
treatment  was  not  enforced.  Violent  nervous  disturbances  occurring 
at  the  time  of  the  secondary  eruption  and  disappearing  with  it  do  not 
necessarily  indicate  a  future  determination  of  the  disease  to  the  brain 

904 


SYPHILIS   OF   THE   NEEVOTJS  SYSTEM.  905 

or  the  spinal  cord  ;  but  if  these  disturbances  increase  after  the  disap- 
pearance of  the  cutaneous  eruption,  or  if  after  disappearing  they  re- 
appear, the  prognosis  as  regards  cerebropathies  must  be  guarded. 

Time  of  Appearance. — Cerebral  syphilomata  are  the  most  pre- 
cocious of  all  the  tertiary  manifestations ;  the  nervous  centres  may 
be  attacked  at  any  period  of  the  disease  after  the  beginning  of  the 
secondary  stage.  The  average  time,  hov^^ever,  for  their  appearance  is 
in  the  third  and  fourth  years  after  infection,  but  they  may  manifest 
themselves  even  as  late  as  eighteen  years  after  the  infecting  chancre. 
Later  than  this  they  are  of  greater  rarity. 

Pathology. — Brain-lesions  of  syphilis  may  appear  as  areas  of 
sclerosis  or  of  softening  and  atrophy,  or  gummata  may  develop.  In 
either  case  the  pathology  is  the  same.  There  are  cellular  prolifera- 
tion and  formation  of  vascularized  granulation- tissue,  usually  diffuse 
in  the  case  of  the  central  nervous  system  and  its  meninges,  and 
ultimately  resulting  in  atrophy  and  sclerosis.  Exceptionally  cellular 
proliferation  is  circumscribed  and  extensive,  forming  gumma.  As- 
sociated with  these  changes,  or  developing  independently  of  them, 
syphilitic  arteritis  is  a  prime  factor  in  the  causation  of  brain-  and 
cord-lesions. 

Gummata  are  formed  v^^ith  far  less  frequency  in  the  cerebral  tissue 
proper  than  in  the  bones  of  the  skull,  or  in  the  meninges  or  the 
subarachnoid  space.  When  they  form,  hov^ever,  they  assume  the 
same  general  appearance  as  elsev^here.  They  are  seldom  smaller 
than  a  pea  or  larger  than  an  egg,  are  very  consistent,  v^ith  a  caseous 
dry  core,  and  are  surrounded  by  highly  vascular  cerebral  tissue  con- 
taining numerous  embryonal  connective-tissue  cells. 

Gummata  are  commonly  found  in  groups  of  three  or  four ;  they 
may  be  single  or  multiple.  Although  they  may  be  found  throughout 
the  brain,  they  usually  graw  from  the  dura  mater  or  the  subarach- 
noid space  at  the  base  of  the  cerebral  hemispheres  near  the  pituitary 
body,  or  on  the  convexity  about  the  frontal  convolutions. 

It  is  at  times  extremely  difficult  to  distinguish  a  large  tubercle  of 
the  brain  from  gumma.  The  symptoms  v^ill  be  the  same.  An  au- 
topsy show^s  the  tubercle  as  a  somewhat  regular  and  sharply  defined 
tumor,  with  no  extensions  into  the  surrounding  tissue,  frequently  ex- 
hibiting miliary  tubercles  about  the  periphery,  and  at  times  having 
undergone  almost  complete  caseous  degeneration.  These  are  char- 
acteristics never  observed  in  gummata.  The  vessels  in  the  tuber- 
cular mass  are  obliterated  ;  in  large  gummata  the  vessels,  even  to  the 
centre,  are  pervious.  Tubercle  is  found  far  more  frequently  in  the 
young,  and  is  usually  associated  with  miliary  deposits  elsewhere  in 


906  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

the  body.  Nowhere  else,  however,  have  these  two  lesions  such 
similarity  as  in  the  brain. 

Gumma-formation  in  the  brain  is  not  a  rapid  process  ;  it  increases 
slowly  up  to  a  certain  point,  and  then  remains  a  long  time  station- 
ary unless  by  its  size  the  gumma  occludes  blood-vessels  and  there- 
upon sets  up  a  passive  hypersemia  or  ischemia  with  consequent 
softening,  which  is  the  natural  tendency  of  all  such  neoplasms. 
Under  antisyphihtic  treatment,  however,  gummata  may  be  appar- 
ently absorbed,  or  at  least  checked,  and  then,  not  infrequently,  a 
post-mortem  discloses  on  the  surface  of  the  brain  characteristic  cica- 
trices or  depressions,  which  are  the  remains  of  the  pre-existing  gum- 
mata, of  which  the  patient  had  been  apparently  cured  for  many  years. 

Intracranial  syphilitic  processes  never  involve  the  entire  tissue 
wherein  they  are  situated,  but  are  apt  to  develop  from  several  foci 
situated  on  any  of  the  intracranial  tissues.  They  seldom  attain  a  large 
size,  and  even  the  pseudo-membranous  patches  of  the  dura  mater, 
which  are  more  diffuse  or  extensive  than  gummata,  never  cover  com- 
pletely the  surfaces  of  the  membrane  over  the  hemispheres.,  wherein 
they  differ  from  the  ordinary  congestive  and  inflammatory  processes. 

Syphilitic  processes  in  general  are  far  more  frequently  found  on 
the  surface  of  the  brain  and  on  the  meninges  than  deep  in  the  cerebral 
substance.  Their  most  frequent  seat  is  on  the  frontal  portions  and  on 
the  base  of  the  brain  in  the  sphenoidal  region. 

In  addition  to  the  gummatous  and  sclerotic  lesions,  which  are  the 
direct  product  of  syphilis,  there  are  lesions  dependent  on  inflam- 
matory or  ischsemic  processes, — the  sequelae  of  syphilitic  endarteritis. 
This  endarteritis  brings  about  a  narrowing  of  the  calibre  of  the 
vessels,  producing  a  lessened  blood-supply  and  consequent  inter- 
ference with  function.  As  this  narrowing  increases,  thrombosis  may 
occur,  wdth  complete  obliteration,  in  consecjuence  of  which,  if  the 
vessel  affected  is  a  terminal  artery,  the  portion  of  the  brain  supplied 
by  this  vessel  degenerates.  When  the  basilar  arteries  are  involved, 
the  free  collateral  circulation  prevents  any  symptom,  even  though  the 
process  has  advanced  to  the  formation  of  thrombosis.  From  this 
clot,  however,  an  embolus  may  be  loosened,  which  wall  produce  the 
same  symptoms  as  a  cerebral  embolism  occurring  in  the  course  of  any 
other  disease. 

The  degeneration  of  the  arteries,  whether  caused  by  syphilis  direct 
or  by  the  proximity  of  syphilitic  lesions,  is  perhaps  the  most  important 
factor  in  the  cerebropathies  of  syphilis,  particularly  in  regard  to  soft- 
ening and  hemorrhages.  When  syphilis  attacks  the  bones  of  the  skull 
there  may  be  cerebral  symptoms,  caused  either  by  an  actual  infection 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  997 

of  the  brain  or  by  a  mechanical  compression  arising  from  a  gum- 
matous formation  or  by  the  presence  of  pus  between  the  bones  of 
the  skull  and  the  dura  mater.  It  is  rare  that  the  brain-substance  at 
the  point  of  osseous  lesion  is  not  affected. 

Of  the  envelopes  of  the  brain  the  dura  mater  is  the  most  frequent 
seat  of  syphilitic  lesions,  not  only  because  they  are  prone  primarily  to 
develop  here,  but  also  because  the  osseous  lesions  imphcate  this 
membrane. 

In  the  patches  of  chronic  syphihtic  pachymeningitis  there  is  little 
to  characterize  as  specific ;  in  all  respects  they  resemble  patches  of 
pachymeningitis  produced  by  any  other  cause.  When  situated  on 
the  upper  surface  of  the  membrane  these  sclerotic  patches  can  in- 
volve large  areas  without  giving  rise  to  appreciable  symptoms,  but 
when  situated  in  the  membrane  surrounding  the  canals  of  exit  of  the 
nerves  they  become  highly  dangerous, 

Gummata  of  the  dura  mater  may  occur  on  either  surface  of  that 
membrane,  and  are  round  in  shape,  of  firm  consistence,  sometimes  a 
little  soft,  almost  never  hc|md.  One  or  more  may  be  present,  from 
the  size  of  a  millet-seed  to  that  of  an  egg ;  they  are  grayish  in  color, 
with  a  firm  centre.  The  adjoining  nerves  are  atrophied,  and  the  arte- 
ries may  be  not  only  obstructed  by  compression  but  invaded  by  the 
gummatous  material,  or  even  obliterated.  Obliteration  of  the  carotid, 
middle  meningeal,  and  basilar  arteries  has  been  noted.  In  a  case 
of  gumma  of  the  tentorium  cerebelli  all  the  sinuses  bordering  on  the 
torcular  Herophih  were  obliterated  (Dowes), 

Syphilomata  of  the  arachnoid  are  rare,  and  appear  as  opalescent 
spots  more  or  less  thickened.  They  are  either  diffuse  or  grouped 
in  compact  masses  in  the  centres  of  which  are  gray  degenerations. 
True  gummata  are  very  rarely  found. 

The  pia  mater  is  the  cranial  tissue  wherein  the  development  of 
syphilitic  meningitis  is  by  far  the  most  frequent. 

From  this  membrane  the  greater  part  of  the  sclerotic  and  gum- 
matous changes  start,  subsequently  invading  the  other  portions  of 
the  encephalon.  The  lesions  are  more  often  of  a  fibro-cellular  char- 
acter than  gummatous,  and  assume  the  form  of  plates  or  bands, 
following  the  course  of  vessels,  most  frequently  along  the  edge  of  the 
fissure  of  Sylvius.  They  consist  merely  of  opalescent  patches,  with 
a  slight  thickening  of  the  membranes.  Their  tendency  to  extend 
along  the  vessels  or  nerves  often  produces  symptoms  of  circum- 
scribed ischsemia  and  cerebral  malnutrition,  as  w^ell  as  neuralgias 
and  paralyses  of  certain  nerves.  The  motor  nerves  of  the  eye  and 
the  fifth  pair  are  most  liable  to  be  thus  affected. 


908  GENITO-FKINAEY   DISEASES  AND  SYPHILIS. 

The  post-mortem  appearance  of  these  lesions  shows  a  close  union 
of  the  membranes  of  the  brain,  with  perhaps  a  sKght  adhesion  to  the 
cerebral  cortex.  True  gummata  in  the  pia  mater  are  not  quite  so 
common  as  in  the  dura ;  they  may  attain  large  size.  They  are  most 
frequently  found  in  the  frontal  regions  and  at  the  base  of  the  brain 
near  the  sella  turcica.  Small  gummatous  nodules  also  form  along  the 
arteries,  and  impinge  not  only  on  the  brain  but  on  the  arteries  them- 
selves, at  first  obstructing  their  lumina  and  afterwards  obliterating 
them,  thus  producing  ischeemia  of  the  brain. 

The  nerves  of  the  membrane  may  likewise  suffer  and  become 
atrophied  by  compression. 

The  arteries  of  the  brain  are  always  more  or  .less  implicated, 
either  primarily  or  consecutively. 

When  they  are  themselves  the  seats  of  syphilitic  degeneration  they 
influence  the  nervous  system  directly  by  means  of  aneurismal  dilata- 
tion or  by  hemorrhages  which  press  upon  the  brain-substance.  Indi- 
rectly, syphilis  of  the  arteries  can  affect  the  brain  by  narrowing  the 
lumen  of  the  vessels  and  by  destroying  their  elasticity,  thus  cutting 
off  the  blood-supply  ;  all  the  symptoms  of  cerebral  ischsemia  there- 
upon follow.  A  thorough  post-mortem  microscopical  examination  is 
sometimes  required  to  reveal  the  numerous  miliary  aneurisms  along 
the  smaller  arteries  and  capillaries  or  the  obliteration  of  these  ves- 
sels.    Syphilis,  then,  may  attack  the  brain  in  the  form  of: 

1.  Diffuse  gummatous  infiltration  of  the  meninges,  with  extension 
to  the  brain-substance. 

2.  Gummata,  or  circumscribed  tumors, 

3.  Endarteritis,  with  its  concomitant  brain-lesions. 
Symptomatology. — An  examination  of  the  symptoms  of  syphihs  of 

the  cerebrum  and  of  its  envelopes  must  include  all  known  symp- 
toms. But,  while  there  exists  no  one  pathognomonic  sign  to  serve 
as  a  guide,  there  are,  nevertheless,  groups  of  symptoms,  subjective 
or  objective,  which  are  fairly  distinctive. 

In  general,  syphilitic  neuroses  are  characterized  by  multipHcity  and 
incoordination  of  symptoms  of  either  gradual  or  rapid  development. 

Except  headache,  disturbances  of  sensation,  whether  neuralgias  or 
anaesthesias,  are  not  commonly  due  to  syphilis  when  they  predom- 
inate over  the  other  symptoms.  On  the  other  hand,  disturbances  of 
motility  are  frequent.  Cerebral  syphihs  will  inevitably,  sooner  or 
later,  if  left  to  itself,  develop  a  paralysis  or  paresis.  The  neurosis 
may  be  at  first  revealed  by  epileptiform  convulsions,  but  eventually 
paresis  sets  in,  together  with  other  symptoms  of  cerebral  softening, 
rapid  loss  of  memory,  and  weakened  cerebration. 


SYPHILIS   OF   THE   NERVOUS   SYSTEM.  909 

As  a  prodromal  symptom  headache  is  chiefly  characteristic. 
This  varies  greatly  in  intensity.  It  is  worse  at  night,  and  is  usually 
constant,  is  deep-seated  and  extremely  harassing,  and  is  accompanied 
by  a  certain  failure  in  mental  power,  a  lack  of  ability  to  concentrate 
the  attention,  and  a  condition  of  nervousness  characterized  by  fore- 
boding and  a  marked  excitement  from  trifling  causes.  There  are  often 
vertigo,  insomnia,  and  profound  mental  depression. 

When  the  syphilitic  process  is  circumscribed,  as  in  the  case  of  a 
gumma  or  of  an  aneurism  due  to  syphilitic  arteritis,  the  pain  is  re- 
stricted to  a  limited  area,  and  is  described  as  like  that  of  a  nail  being 
driven  into  the  head.  When  patches  of  sclerosis  are  extensive,  the 
cephalalgia  may  cover  all  one  side  of  the  head. 

Fournier  has  described  this  symptom  and  its  indications  as  fol- 
lows :  Pain  in  the  head  is  one  of  the  most  frequent  manifestations  of 
secondary  syphilis.  The  prodromal  headache  of  tertiary  encepha- 
lopathies is  universally  recognized.  It  is  unfortunate  that  the  terni 
specific  cephalalgia  conveys  the  impression  of  a  single  pathological 
process,  when,  as  a  matter  of  clinical  fact,  the  lesions  are  often 
widely  diverse  in  their  nature.  The  single  symptom  common  to  all 
is  pain  in  the  head. 

Aside  from  syphilitic  affections  of  the  brain  and  its  meninges,  the 
true  specific  encephalalgias,  the  pain  may  be  due  to  the  specific  poison 
affecting  one  or  more  of  the  cranial  nerves,  constituting  what  may  be 
called  neuralgic  headache.  Or  it  may  be  due  to  lesions  of  the  cranial 
bones,  such  as  periostosis  or  gummatous  osteoma,  causing  bone  pain. 
Or  it  may  develop  as  bone  neuralgia  without  demonstrable  lesion,  in 
which  case  it  is  often  impossible  to  locate  it.  In  many  respects  it 
does  not  differ  from  headaches  due  to  causes  other  than  syphilis. 
Finally,  there  is  a  headache  which,  though  dependent  on  syphihs, 
is  not  syphilitic  in  nature ;  in  other  words,  it  is  a  parasyphiHtic 
neurosis. 

Syphilitic  neuralgias  are  not  headaches  in  the  true  sense  of  the 
word ;  the  pain  is  located  in  the  trunk  or  branches  of  distribution  of 
a  given  nerve,  and  is  aggravated  by  pressure  along  the  course  of  this 
nerve,  particularly  at  its  point  of  emergence  from  the  bone.  This 
pain  most  frequently  attacks  the  fifth  pair,  and  has  for  its  type  supra- 
orbital neuralgia.  It  is  observed  during  the  early  stage  of  the  sec- 
ondary period, — that  is,  in  the  first  six  or  eight  months  of  the  disease. 
It  is  impossible  to  state  whether  or  not  it  is  dependent  upon  organic 
lesion.  When  it  occurs  during  the  tertiary  period  it  is  nearly  always 
due  to  a  distinct  infiltration ;  sometimes  it  is  caused  by  the  pressure 
of  a  gumma  or  bony  outgrowth.     These  specific  neuralgias  exhibit 


910  GEXITO-UKINAKT  DISEASES  AND   SYPHILIS. 

almost  the  same  sjTuptoms  that  distinguish  neuritis  from  other  causes. 
They  have,  however,  a  tendency  to  become  worse  at  night,  and  yield 
promptly  to  specific  treatment.  Indeed,  the  therapeutic  test  is  the 
only  means  of  making  a  positive  diagnosis. 

Headache  from  Bone-Lesioxs. — Pain  due  to  bone-involvement  may 
occur  in  the  early  stages,  during  the  height  of  the  disease,  or  at  a  late 
tertiary  period.  It  is  most  frequent  in  the  tertiary  period,  and  is 
then  readily  recognized,  since  the  lesions  are  gross,  producing  con- 
siderable deformity. 

Secondary  lesions  are  slight,  circumscribed,  and  readily  over- 
looked, especially  when  they  develop  in  the  hairy  scalp.  They  occur 
during  this  early  period  as  periostitis,  periostosis,  or  ostealgia  char- 
acterized by  circumscribed  areas  of  hyperaesthesia  without  appreciable 
infiltration.     These  lesions  are  very  common,  especially  in  women. 

The  periostites  produce  slight  circumscribed  swelling  of  the  bone, 
particularly  in  the  parietal,  temporal,  and  frontal  regions.  The  in- 
volved areas  are  small, — about  the  size  of  a  ten-cent  piece,  some- 
times as  large  as  a  fifty-cent  piece, — very  slightly  raised,  sometimes 
obscurely  fluctuating.  They  are  painful  and  extremely  sensitive. 
This  excessive  sensibility  is  a  characteristic  sign. 

Periostoses  give  the  same  symptoms,  and  are  even  more  painful. 
They  are,  however,  more  dense  and  resistant  and  last  longer.  There 
is  true  bony  proliferation. 

The  ostealgias  are  characterized  solely  by  pain  and  tenderness. 
There  is  neither  swelling  nor  appreciable  alteration  of  any  kind.  The 
pathological  basis  of  this  symptom  is  absolutely  unknown.  The  pain 
is  sometimes  agonizing,  and  often  radiates  over  a  large  surface.  The 
diagnosis  is  founded  upon  careful  and  thorough  palpation  of  the  entire 
cranium. 

Headaches  due  to  syphilitic  affections  of  the  brain  or  its  enve- 
lopes are  more  diffuse  and  more  deeply  placed  than  those  dependent 
upon  bony  lesions  or  upon  neuralgias.  It  is  impossible  from  the 
symptoms  to  decide  whether  they  are  caused  by  lesions  of  the  me- 
ninges, of  the  cerebrum,  or  of  the  blood-vessels,  or  whether  all  these 
structures  are  involved. 

Clinically,  three  varieties  are  recognized :  1,  secondary  enceph- 
alalgia ;  2,  headache  symptomatic  of  cephalic  lesions  ;  3,  parasyphilitic 
headache,  due  to  hysteria  or  neurasthenia. 

Secondary  syphilitic  headache,  which  develops  during  the  early 
periods  of  this  stage  of  the  disease,  is  very  common,  especially  in 
women ;  indeed,  in  them  when  untreated  it  is  usually  severe  and 
prolonged.   The  pain  is  felt  within  the  head.    It  is  general,  but  especially 


SYPHILIS   OF   THE   NERVOUS   SYSTEM.  911 

severe  in  the  regions  of  the  forehead,  the  temples,  and  the  occiput,  'rtie 
pain  maybe  described  as  a  feeling  of  weight  in  the  head,  or  a  beating, 
or  a  sense  of  pressure  ;  sometimes  it  is  lancinating  or  tearing,  as  if 
the  cranium  were  about  to  burst.  The  pain  varies  greatly  in  inten- 
sity ;  it  may  be  slight,  bearable,  not  interfering  with  the  pursuits  of 
life ;  or  as  severe  as  an  ordinary  migraine,  preventing  work,  particu- 
larly that  requiring  much  thought,  and  disturbing  sleep  ;  or  agonizing 
and  absolutely  unbearable. 

Associated  with  the  headache  there  are  usually  diminution  of  ap- 
petite, disordered  digestion,  general  malaise,  nervous  erethism,  great 
excitability,  and  sometimes  disturbance  of  vision,  with  vertigo.  The 
patient  becomes  morose,  melanchohc,  stupid,  and  forgetful. 

These  headaches  may  assume  the  intermittent  type  or  the  con- 
tinuous type  with  exacerbations.  The  intermittent  type  is  most  fre- 
quent, especially  in  the  slight  forms  and  those  of  medium  severity. 
The  pain  usually  comes  on  at  about  five  or  six  o'clock  in  the  evening 
and  disappears  during  the  night,  often  recurring  at  the  same  hour  and 
in  the  same  form  day  after  day  and  following  the  same  course. 

The  continuous  type  with  exacerbations  is  less  frequent.  In  these 
cases  the  headache  never  disappears  entirely ;  but  here  again  the 
exacerbation  is  observed  in  the  evening  or  during  the  night. 

In  some  cases  these  secondary  headaches  disappear  in  a  few  days 
or  one  or  two  weeks.  Usually  they  persist  for  several  weeks,  or  even 
for  several  months. 

Diagnosis. — The  diagnosis  is  founded  on  the  nocturnal  exacer- 
bations and  the  prompt,  characteristic,  and  extraordinarily  curative 
effect  of  specific  treatment.  Night  exacerbations  of  cephalalgia  are 
not  confined  to  syphihs.  From  the  symptoms  alone  these  headaches 
cannot  be  distinguished  from  those  of  anaemia,  of  hysteria,  or  of  rheu- 
matism. Fortunately,  syphilitic  headache  is  commonly  associated 
with  other  incontestable  signs  of  the  disease  or  with  a  history  which 
is  suggestive.  Usually  there  are  syphilides  or  alopecia  and  articular 
pains.  In  the  rare  cases  where  both  history  and  concomitant  symp- 
toms of  syphihs  are  wanting,  an  ehmination  of  other  causes  of  ceph- 
alalgia would  suggest  syphilis  and  consequently  specific  treatment. 
Thus,  neuralgic  cephalalgia  would  be  distinguished  by  pain  referred 
to  certain  points  along  the  course  of  nerves ;  migraine,  by  compara- 
tively long  periods  of  remission ;  rheumatic  cephalalgia,  by  super- 
ficial, muscular  pain,  increased  on  contraction  of  muscles,  and  reheved 
by  heat ;  anaemic  cephalalgia,  by  the  facts  that  it  lessens  during  the 
evening,  that  it  is  made  better  by  eating,  and  that  it  is  accompanied 
by  other   symptoms  of  lessened  haemoglobin ;    neurasthenic  cepha- 


912  GEXITO-UEIXAKT  DISEASES  AND   SYPHILIS. 

lalgia,  by  its  less  severe  pain,  its  partly  diurnal  character,  and  its  long 
continuance. 

Treatment. — The  specific  treatment  of  secondary  cephalalgia  is 
attended  by  prompt  results.  Inunctions  and  full  doses  of  potassium 
iodide  should  be  given. 

Prodrojul  Cephalalgia  of  Tertl^rt  Lesions. — The  most  important 
variety  of  specific  migraine  is  that  preceding  the  grosser  symptoms  of 
cerebral  syphilis.  In  certainly  two-thirds  of  all  cases  of  hemiplegia, 
amnesia,  aphasia,  epilepsy,  coma,  pseudo-paralysis,  etc.,  dependent 
upon  syphihs,  there  is  this  prodromal  headache.  A  large  percentage 
of  these  cases  could  have  been  saved  from  these  grave  accidents  by 
vigorous  treatment  instituted  during  the  prodromal  jDeriod. 

This  headache  differs  from  other  cephalalgias,  as.  for  instance, 
those  due  to  neuralgia  or  to  epicranial  rheumatism,  in  the  fact  that  it 
is  felt  to  be  deep  within  the  head.  The  character  of  the  pain  varies : 
1,  there  may  be  simply  a  sense  of  weight  and  hebetude  ;  2,  there 
may  be  a  constrictive  pain,  as  though  the  head  were  screwed  in  a 
vice ;  3,  the  sensation  may  resemble  that  produced  by  blows  of  a 
hammer,  the  suffering  being  intense  and  the  pain  deeply  placed. 
These  three  types  may  be  associated  or  may  succeed  one  another. 

The  pain  may  be  sharply  circumscribed  to  an  area  not  larger  than 
a  half-dollar.  In  this  case  it  frec{uently  indicates  the  formation  of  a 
gumma.  Sometimes  it  is  diffuse,  occupying  a  general  region,  as  the 
frontal,  temporal,  parietal,  or  occipital,  or  is  spread  over  two  or  more 
of  these  regions.  Exceptionally  it  seems  to  involve  the  whole  head. 
The  fronto-parietal  region  is  the  one  to  which  this  pain  is  most  fre- 
quently referred.  This  form  of  cephalalgia  has  three  characteristics 
which  should  at  least  strongly  suggest  its  nature:  1.  there  is  an 
habitual  intensity,  sometimes  extraordinary  severity,  of  pain ;  2,  it  is 
persistent,  tenacious,  long-lasting ;  3.  there  are  nocturnal  exacerba- 
tions. 

Even  in  mild  cases  the  pain  is  less  bearable  than  the  ordinary 
headache  ;  it  harasses  the  sufferers,  making  them  despondent,  morose, 
excitable,  and  sleepless,  and  interferes  with  general  nutrition  ;  or  it 
may  be  so  severe  as  completely  to  prostrate  them.  Exceptionally  the 
pain  amounts  to  a  veritable  anguish,  comparable  in  intensity  to  that 
of  hepatic  or  nephritic  colic. 

As  a  rule,  syphilitic  cephalalgia  precedes  the  grave  developments 
of  brain-syphilis  by  an  interval  of  from  three  to  six  weeks  :  it  is,  how- 
ever, not  uncommon  for  this  pain  to  last  from  three  to  six  months ; 
exceptionally  the  pain  may  exhibit  remissions  and  exacerbations  for 
two  or  three  years.    Under  the  influence  of  intermittent  mild  specific 


SYPHILIS    OF    THE   [J^ERYOUS    SYSTEM.  913 

treatment  the  headache  may  be  temporarily  cured,  to  recur  time 
after  time,  till  symptoms  such  as  hemiplegia  or  epilepsy  show  that 
irreparable  damage  has  been  done. 

Nocturnal  exacerbations  of  pain,  though  the  rule,  are  by  no  means 
invariable.  In  the  secondary  period  this  characteristic  is  most  pro- 
nounced ;  in  the  tertiary  period  it  may  be  wanting  entirely ;  indeed, 
there  may  even  be  nocturnal  remissions. 

The  prodromal  headache  of  tertiary  syphilis  is  a  sign  of  inestimable 
value,  enabling  treatment  to  be  adopted  in  time  to  prevent  grave  lesions. 

Treatment. — The  treatment  should  be  instituted  early,  and  should 
be  sufficiently  thorough  to  cure  the  headache  and  to  eradicate  as  far 
as  possible  the  underlying  constitutional  taint.  Mercury  and  potas- 
sium iodide  should  be  given  in  the  most  active  manner  possible. 
Daily  hypodermic  injections  of  corrosive  chloride  or  inunctions  of  mer- 
cury ointment  should  be  given  in  full  doses  supplemented  by  the  vapor 
bath.  Internally,  potassium  iodide  should  be  rapidly  pushed  to  the 
extreme  point  of  toleration :  to  a  woman,  one  to  one  and  a  half 
drachms  a  day ;  to  a  man,  nearly  twice  this  dose.  This  treatment 
should  be  long  continued,  with  appropriate  short  intervals  of  rest, 
until  there  is  good  reason  to  believe  that  there  is  no  likelihood  of 
recurrence.  Fournier  has  relieved  the  agonizing  cephalalgia  of  high 
tension  by  lumbar  puncture. 

Parasyphilitic  Cephalalgia. — Among  the  parasyphilitic  headaches 
may  be  mentioned  the  neuralgic  migraine  and  the  crises  of  pain  often 
observed  in  tabes.  The  most  important  cause  of  these  headaches, 
and  by  far  the  most  common,  is  neurasthenia.  This  is  an  ordinary 
sequel  of  syphilis,  and  among  its  multitudinous  symptoms  none  is 
more  troublesome  or  more  frequent  than  headache. 

This  parasyphilitic  neurasthenic  headache  is  characterized  by 
moderate  intensity ;  it  is  not  really  a  pain,  but  rather  a  sensation 
of  weight  or  constriction,  of  dulled  or  imperfect  cerebral  action.  It 
usually  lasts  several  years.  It  is  present  in  the  morning  on  rising; 
is  sometimes  better  after  meals,  but  shortly  returns  with  its  original 
intensity,  or  even  with  a  slight  excess  of  this  ;  it  is  better  at  night,  so 
that  sleep  is  not  disturbed.  It  is  not  benefited  by  specific  treatment ; 
it  is  usually  located  in  the  occipital  region ;  and  it  is  often  associated 
with  other  signs  of  neurasthenia.  These  are  characteristics  which 
sufficiently  distinguish  this  cephalalgia  from  pain  preceding  the  recog- 
nized cephalopathies  ;  indeed,  a  headache  which  has  lasted  for  several 
years  almost  certainly  does  not  belong  to  the  latter  class,  since  apo- 
plexy or  some  one  of  the  serious  symptoms  denoting  irreparable  brain- 
lesion  is  certain  to  develop  long  before  the  expiration  of  this  period. 

58 


914  GENITO-UEINAET  DISEASES  AND  SYPHILIS. 

Yet  it  may  well  happen  that  a  differential  diagnosis  cannot  be  made. 
In  this  case  the  mixed  specific  treatment  should  be  given  one  thorough 
trial.  Should  it  fail,  there  should  be  no  further  effort  in  the  direction 
of  attempting  cure  by  this  treatment. 

When  the  diagnosis  of  parasyphilitic  neurasthenia  is  firmly  estab- 
lished, minute  attention  to  general  hygiene,  thorotigh  hydrotherapy, 
especially  with  douches  of  brief  duration,  and  congenial  surroundings, 
represent  the  best  methods  of  accomplishing  a  cure.  The  only  drug 
which  is  of  the  least  service,  aside  from  tonics  and  nutritives,  is  potas- 
sium bromide  ;  this  sometimes  relieves  the  headache. 

But  we  cannot  affirm  that  all  grave  syphilitic  cerebropathies  are 
preceded  by  these  headaches.  Mauriac  quotes  a  case  in  which  a  man 
aged  twenty-two  M^as  suddenly  seized  with  severe  convulsions  of  the 
left  arm,  which  were  undoubtedly  due  to  syphilis,  but  v^hich  were 
preceded  by  no  prodromal  headache  or  other  nervous  symptoms. 
Fournier  also  has  noted  a  similar  case  wherein  the  patient  had 
suffered  no  headache  during  the  ailment,  and  yet  the  post-mortem 
disclosed  extensive  syphilitic  disease  of  the  brain. 

Following  these  prodromal  symptoms  there  are  certain  symptoms, 
which  Finger  classifies  as  follows  : 

1.  Psychical  disturbances,  with  epilepsy  accompanied  by  paresis 
not  involving  the  cerebral  nerves,  terminating  in  coma.  In  these 
cases  gummata  and  wide-spread  endarteritis  of  the  convexity  of  the 
brain  are  found. 

Following  the  prodromes  or  without  symptoms  there  is  a  sudden, 
often  violent,  epileptic  attack,  sometimes  not  accompanied  by  com- 
plete loss  of  consciousness.  This  is  followed  by  cerebral  irritability 
and  fatigue,  mental  failure,  progressing  to  dementia,  localized  mus- 
cular weakness,  paresis  or  paralysis  which  may  be  of  irregular  dis- 
tribution, and  slow,  halting  speech. 

2.  Apoplectic  attacks  followed  by  hemiplegia  associated  with  som- 
nolence, with  symptoms  of  irritation  of  one  side  and  paralysis  of  the 
cerebral  nerves. 

In  these  cases  there  are  gummatous  infiltration  of  the  base  and 
arteritis  involving  the  vessels  of  the  large  central  ganglia.  Following 
prodromal  symptoms  there  is  suddenly  developed  palsy  of  one  or 
more  cranial  nerves,  the  oculo-motor  and  abducens  being  most  fre- 
quently involved.  This  will  be  shown  by  ptosis,  strabismus,  loss  of 
accommodation,  etc.  These  palsies  are  persistent,  and  may  be  pre- 
ceded or  accompanied  by  twitchings  or  contractions  of  the  muscles 
supplied  by  the  affected  nerves.  Following  these  symptoms,  or 
someti^nes  preceding  them,  there  is  an  apoplectic  attack,  often  not 


SYPHILIS   OP   THE   NEEVOUS   SYSTEM.  915 

attended  by  loss  of  consciousness,  but  with  hemiplegia  and  disturb- 
ance of  speech.  Even  when  this  stage  is  reached  almost  complete 
restoration  of  mental  power  is  possible.  If  the  disease  is  progressive, 
other  apoplectic  attacks  supervene,  the  mind  becomes  dull  and  list- 
less, there  are  involuntary  micturition  and  defecation,  and  finally  coma 
and  death  supervene. 

3.  Psychoses,  appearing  generally  in  the  form  of  paralytic  demen- 
tia or  progressive  paralysis. 

These  psychoses  are  usually  accompanied  by  paresis  or  paralysis, 
especially  of  the  cranial  nerves,  and  by  epileptiform  attacks. 

The  syphilitic  cerebropathies  are  most  commonly  characterized 
by  a  slow  but  steady  advance ;  thus,  a  slight  neuralgia  expands 
into  epileptiform  convulsions,  and  finally  ends  with  paresis  or  pa- 
ralysis. 

Diagnosis  of  Intracranial  Syphilis. — In  general  it  may  be  af- 
firmed that  all  non-traumatic,  non-cardiac  cerebropathies  found  in 
persons  of  previously  good  health  between  the  ages  of  twenty  and  forty 
are  probably  of  syphilitic  origin.  If  there  is  a  history  of  preceding 
chancre  the  diagnosis  is  still  further  assured.  Epilepsy,  if  idiopathic 
or  inherited,  always  makes  its  appearance  in  childhood ;  when  it 
occurs  late  in  life  and  is  non-traumatic  it  is  exceptional,  and  is  then 
probably  due  to  syphilis.  Paresis,  not  of  toxic  or  traumatic  origin, 
occurring  between  the  ages  of  twenty  and  forty,  is  due  to  syphilis  in 
eighty  per  cent,  of  cases.  In  nervous  disorders  wherein  two  diatheses 
are  possible  causes,  for  instance,  the  gouty  and  the  syphilitic,  the  diag- 
nosis is  to  a  certain  extent  dependent  upon  the  therapeutic  test. 

A  gouty  diathesis  is  apt  to  produce  nervous  symptoms  only  late  in 
life,  but  in  all  other  respects  gouty  and  syphilitic  cerebropathies  may 
be  almost  identical.  In  both  gout  and  syphilis  arterio-sclerosis  is  a 
common  feature,  and  the  same  symptoms  would  follow  from  whatever 
cause  the  lesion  was  produced. 

Even  the  therapeutic  test  is  not  wholly  trustworthy  in  deciding  as 
to  the  specific  nature  of  palsies.  Paralysis  of  the  facial  nerve,  though 
strongly  suggesting  syphilis,  is  not  pathognomonic,  since  facial  paraly- 
sis may  be  produced  by  cold,  and  may  be  only  a  transitory  affection, 
which  disappears  under  full  doses  of  potassium  iodide  simply  because 
it  has  run  its  course.  It  is  always  possible  that  the  paralysis  may 
have  been  an  independent  acute  attack,  and  might  have  disappeared 
of  itself  without  treatment. 

Attention  has  been  called  to  the  fact  that  the  symptoms  of  cere- 
bral syphilis  are  often  attributed  to  slight  disorders,  and  hence  treat- 
ment is  not  instituted  at  the  time  that  it  is  most  valuable. 


916  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

In  forming  a  diagnosis  a  minute  study  of  the  previous  history  is 
imperative,  as  well  as  careful  observation  of  the  entire  symptom-com- 
plex. The  diagnosis  will  then  be  founded  on  a  syphilitic  history,  a 
prodromal  headache  persistently  worse  at  night,  and  often  associated 
with  vertigo,  impaired  mental  activity,  localized  paresis,  epileptiform 
or  apoplectiform  attacks,  not  necessarily  attended  with  loss  of  con- 
sciousness, hemiplegia  and  paralysis  particularly  involving  the  cranial 
nerves,  marked  psychoses,  and  coma.  These  symptoms  are  some- 
what irregular,  but  progressive.  They  are  checked  by  specific  treat- 
ment. Vertigo  is  of  significance  only  when  associated  with  headache; 
it  is  aggravated  by  excitem.ent  or  sudden  change  of  posture,  and  may 
merge  into  transient  unconsciousness.  Insomnia  is  the  rule  in  pa- 
tients under  fifty,  who  are  often  unable  to  sleep  at  all  during  the  first 
part  of  the  night.  This  insomnia  bears  a  relation  to  the  intensity  of 
the  headache,  and  disappears  with  the  latter  on  the  onset  of  paralysis. 
Somnolence  is  observed  in  patients  over  fifty. 

The  paralysis  that  develops  during  sleep  is  probably  due  to  a 
thrombus,  that  which  occurs  during  brain  activity  is  probably  caused 
by  rupture.  Involvement  of  the  third  nerve  is  so  characteristic  of  intra- 
cranial syphilis  that  ptosis  or  strabismus  developing  suddenly  in  an  adult 
is  diagnostic.  Epilepsy  developing  in  the  adult  is  traumatic,  uraemic,  or 
syphilitic,  and  hemiplegia,  if  not  apoplectic,  is  usually  of  the  same  nature. 

Prognosis. — The  prognosis  is  always  grave  unless  energetic  anti- 
syphilitic  treatment  can  be  instituted  before  the  syphilitic  lesions  have 
produced  actual  destruction  of  nerve  tissue  from  pressure  incident  to 
involvement  of  the  neuroglia  and  adventitious  tissues.  In  most  cases 
a  guardedly  favorable  prognosis  can  be  based  on  a  prompt  response 
to  specific  treatment.  Meningitis,  gummatous  tumors,  many  cases  of 
myelitis  and  paralysis  due  to  thromboses  or  to  endarteritis  obliterans, 
offer  a  prognosis  much  more  favorable  than  do  these  same  conditions 
when  due  to  other  causes.  Locomotor  ataxia,  which  is  specific  in 
origin  in  over  seventy  per  cent,  of  cases,  is  sometimes  apparently  made 
worse  by  specific  treatment.  Syphilitic  epilepsy  in  its  earliest  stages 
may  be  helped  by  treatment ;  later,  because  of  habit,  the  cause  be- 
comes of  minor  importance  so  far  as  cure  is  concerned ;  moreover 
these  patients  are  often  intolerant  of  iodides.  The  prognosis  in  gen- 
eral paralysis  of  the  insane,  even  when  the  cause  is  distinctly  syphilis, 
is  almost  invariably  hopeless  ;  certainly  nothing  positive  can  be  prom- 
ised as  to  the  final  outcome. 

In  a  large  proportion  of  the  cases  of  intracranial  syphilis,  the  lesion 
is  an  endarteritis  obliterans.  Before  the  obstruction  is  complete,  much 
can  be  done  by  active  treatment. 


SYPHILIS   OF   THE   NEEVOUS  SYSTEM.  917 

Treatment — The  treatment  for  cerebral  syphilis  is  the  same  as  that 
for  all  tertiary  lesions, — namely,  a  mixed  treatment  of  potassium  iodide 
and  mercury.  The  potassium  iodide  should  be  started  in  full  doses 
of  thirty  to  forty  grains  daily  and  pushed  rapidly  to  the  point  of  toler- 
ance. Everything  depends  upon  obtaining  a  prompt  action,  and  to 
begin  with  small  doses  of  five  or  six  grains  is  a  dangerous  v^^aste  of 
time.  The  prodromal  period  is  the  time  to  avert  irremediable  de- 
generations and  to  v^ard  off  the  violent  nerve-storms  which  are  sure 
to  follow  if  the  treatment  be  neglected.  Hygienic  measures  are  not 
to  be  ignored,  the  nervous  system  must  be  kept  at  rest,  there  must 
be  no  household  or  business  worries,  and  there  must  be,  if  possible, 
moderate  and  regular  exercise.  Attention  to  the  digestive  tract  is  of 
the  utmost  importance. 

In  convulsive  types  the  bromides  are  Useful ;  antipyrin,  chloral, 
and  chloralamide  are  at  times  of  greatest  service  When  the  pains  are 
intense.  Electricity  should  be  employed  to  exercise  and  stimulate 
the  paralyzed  muscles.  When  rapid  action  of  the  specific  is  impera- 
tive, hypodermic  injections  of  mercury  are  indicated.  Potassium 
iodide  is  most  conveniently  given  in  the  saturated  solution  of  which 
one  minim  contains  one  grain.  The  mercury  may  be  given  hypo- 
dermically  or  by  inunction.  The  limit  of  physiological  toleration  to 
these  drugs  should  be  reached  early  and  maintained  by  full  doses. 

SYPHILIS   OF   THE   SPINAL   CORD. 

Syphihs  of  the  spinal  cord  cannot  be  said  to  have  in  its  symptoms 
the  irregularity  and  incongruity  which  are  the  characteristic  features 
of  cerebral  syphilis.  Myelopathies  due  to  syphilis  correspond  in 
every  respect  to  those  due  to  other  causes.  Syphilis,  however,  is  an 
etiological  factor  of  the  greatest  frequency  in  all  myelopathies,  whether 
distinguished  by  softening  or  by  sclerosis,  either  diffuse  or  circum- 
scribed :  so  that  it  is  almost  justifiable  to  assert  that  any  myelopathy 
of  which  the  cause  is  not  manifest  is  syphilitic. 

The  syphilitic  lesions  which  may  affect  the  cord  and  its  mem- 
branes are  identical  with  those  which  affect  the  brain, — namely,  dif- 
fuse gummatous  infiltration  followed  by  sclerosis,  circumscribed 
gummata,  and  endarteritis.  Myelopathies  occur  with  the  greatest 
frequency  during  the  third  or  fourth  year  after  infection ;  cases, 
however,  have  been  observed  occurring  as  late  as  twenty-five  years 
after  the  contraction  of  syphilis. 

Etiology. — There  is  no  satisfactory  explanation  as  to  why  syphilis 
should  attack  the  cord  in  some  cases  and  not  in  others.  In  addition 
to  the  general  causes  mentioned  when  treating  of  cerebral  syphilis, 


918  GEJSriTO-TJKINARY    DISEASES   AND   SYPHILIS. 

venereal  excess  and,  according  to  Mauriac,  the  influence  of  a  damp 
cold  climate  should  be  included. 

Morel-Lavallee  thinks  that  there  is  special  virulence  in  the  original 
infecting  germ  of  certain  cases  of  syphilis  which  has  a  predilection 
for  the  nervous  system.  He  cites  from  personal  observation  the  cases 
of  five  men  who  contracted  syphilis  from  the  same  source,  and  all 
of  whom  died,  at  varying  periods  after  infection,  from  syphilitic  dis- 
ease of  the  nervous  system,  while, .  strangely  enough,  the  woman 
who  infected  them  married  and  gave  birth  to  a  healthy  child.  This 
special  virulence  he  calls  the  "  verole  nerveuse." 

As  a  rule,  syphiKs  does  not  attack  primarily  the  essential  tissues 
of  an  organ, — as,  for  instance,  the  nerve-cells  themselves :  hence 
gummata  of  the  cord  are  excessively  rare  ;  they  do  occur,  however, 
in  the  centre  of  the  cord,  and  somewhat  more  frequently  on  its 
surface,  adhering  closely  to  the  meninges,  from  which  possibly  they 
originate.  They  present  the  same  appearance  as  gummata  of  the 
cerebrum. 

The  most  common  forms  of  syphilitic  myelopathies  are  sclerosis 
and  softening,  which  are  usually  associated  and  which  may  be  wide- 
spread or  circumscribed.  Softening  often,  not  always,  follows  in  the 
path  of  the  sclerosis ;  it  is  only  exceptionally  a  rapid  process,  and 
where  symptoms  of  spinal  disorder  have  existed  for  a  length  of  time 
is  commonly  found  in  disseminated  patches.  When  the  myelopathy 
has  advanced  rapidly  and  deep  bed-sores  form  in  the  sacral  region, 
the  softening  is  generally  extensive,  without  patches  of  sclerosis. 

Fibrous  degeneration  or  sclerosis  of  the  cord  is  more  frequent 
than  softening,  but  for  the  most  part  the  two  processes  are  so  inti- 
mately associated  that  they  may  be  considered  as  but  two  phases  of 
the  same  process. 

Lesions  of  the  cord  consequent  upon  syphilis  of  its  bony  envelope 
are  far  less  frequent  than  are  the  corresponding  cerebral  lesions ; 
possibly  because  of  the  greater  space  between  the  vertebrae  and  the 
nervous  tissue,  and  also  because  the  vertebree  have  a  periosteal 
envelope  independent  of  the  dura  mater. 

The  meninges  of  the  cord  are  especially  liable  to  be  attacked.  The 
membranes  are  so  intimately  associated  that  it  is  almost  impossible 
to  distinguish  in  which  of  the  three  the  lesion  originated,  since  it 
always  rapidly  spreads  from  one  to  the  other,  thus  making  at  the  in- 
vaded point  one  thick  membrane,  possibly  studded  here  and  there 
with  gummatous  deposits. 

Symptomatology. — The  symptoms  of  myelo-syphilis  present  the 
same  general  characteristics  as  cerebral  syphiloses, — namely,  dissem- 


SYPHILIS   OF   THE    NEKVOUS   SYSTEM.  919 

ination  of  manifestations,  a  marked  tendency  to  temporary  ameliora- 
tion, and  recurrences,  together  with  early  implication  of  the  bladder 
and  rectum. 

The  development  of  symptoms  due  to  compression  of  the  cord  by 
a  syphilitic  osteophyte  is  usually  comparatively  slow,  but  otherwise 
the  same  as  from  compression  due  to  any  other  cause.  When,  on 
the  other*  hand,  syphilitic  disease  of  the  bone  has  gone  to  such  an 
extent  as  to  produce  a  sudden  dislocation  of  the  vertebrae,  then 
symptoms  arise  as  suddenly,  and  vesical  and  rectal  troubles  are 
among  the  first. 

The  paralytic  and  trophic  symptoms  vary  according  to  the  situa- 
tion of  the  compression  or  degeneration.  The  cervical  region  is  most 
frequently  attacked,  and  if  the  compression  is  only  slight  the  upper 
extremities  alone  will  be  affected.  A  point  of  tenderness  can  almost 
always  be  elicited  on  the  spinal  column  opposite  the  lesion  of  the 
cord,  and  in  a  case  of  suspected  cervical  lesion  an  examination  of  the 
throat  should  always  be  made ;  there  is  a  possibility  that  deep  ulcera- 
tions may  indicate  disease  of  the  vertebrae  in  this  region. 

Syphilitic  meningitis  is  rarely  of  an  acute  type  ;  it  more  commonly 
assumes  the  form  of  sclerotic  patches  or  bands  pressing  on  the  cord, 
and  is  manifested  in  much  the  same  manner  as  compression  due  to 
other  causes.  The  dorsal  and  lumbar  pains  are  of  excruciating  in- 
tensity, made  worse  by  motion.  Finally,  paralysis  of  the  extremities 
and  sphincters  supervenes,  and  indicates  that  softening  or  annular 
constriction  of  the  cord  has  commenced. 

Acute  or  subacute  myelo-syphiloses  are  not  as  common  as  the 
chronic,  and  are  often  found  in  secondary  syphiHs.  When  they 
occur  at  a  period  long  after  the  chancre,  with  no  other-  manifesta- 
tion of  the  disease,  the  diagnosis  is  extremely  difficult.  Vesical 
troubles  and  weakness  of  the  lower  limbs  are  usually  the  first  symp- 
toms, which  rapidly  advance  to  paralysis  and  retention  of  urine  and 
faeces,  followed  shortly  by  incontinence  and  the  formation  of  deep 
bed-sores  on  the  sacrum  and  the  heels.  Fever,  if  any  develops,  is 
slight. 

Treatment  is  of  little  avail,  and  death  ensues  in  a  few  days  or 
weeks.  This  acute  myelo-syphilosis  is  the  most  dangerous  of  the 
syphilitic  affections  of  the  cord. 

Chronic  myelo-syphiloses  are  distinguished  not  so  much  by  their 
duration  as  by  the  gradual  development  of  symptoms.  They  are 
much  more  common  than  the  acute  forms,  and  less  likely  to  have  a 
rapid  termination. 

The  first  symptoms  are  usually  overlooked,  and  consist  of  neural- 


920  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

gic  pains,  with  weakness  in  the  limbs.  Slight  difficulties  of  micturi- 
tion and  gradual  enfeeblement  of  sexual  power  follow  in  order.  The 
weakness  gradually  develops  to  paresis  or  paralysis,  and  the  sexual 
power  is  entirely  lost.  The  patient  next  suffers  all  the  excruciating 
pains  and  girdle  symptoms  of  myelitis.  It  is  very  rare  for  disturb- 
ances of  sensation  to  keep  pace  with  the  paralysis.  '  A  part  of  the 
body  entirely  paralyzed  may  still  retain  its  normal  sensibility,  or  else 
the  sensation  may  be  merely  blunted  and  the  patient  be  unable  accu- 
rately to  localize  the  sensation.  The  reflexes  are  at  first  exaggerated, 
but  soon  become  much  diminished  or  abolished.  Bed-sores  are  very 
slow  to  make  their  appearance.  The  symptoms  are  usually  confined 
to  the  lower  extremities,  and  it  is  rare  for  the  process  to  have  a 
tendency  to  ascend  the  cord. 

Under  the  influence  of  specific  treatment  the  disease  may  be 
occasionally  checked  or  even  apparently  cured ;  but  it  must  be  re- 
membered that  temporary  ameliorations  are  characteristic  of  all 
syphilitic  neuroses. 

Tabes  Dorsalis. — In  all  other  myelo-syphiloses  certain  pathological 
elements  can  be  found — namely,  traces  of  gummatous  material — 
which  determine  the  syphihtic  origin  of  the  lesion,  but  in  tabes 
dorsahs  or  locomotor  ataxia  of  syphilitics  search  for  a  pronounced 
syphilitic  element  is  vain.  It  is  only  from  the  evidence  supphed  by 
numerous  statistics  showing  the  association  of  tabes  dorsalis  with 
syphilis  that  we  can  infer  a  connection  between  the  two. 

The  tabes  which  attacks  syphilitics  is  identical  with  that  which 
attacks  those  who  have  not  the  slightest  syphilitic  taint.  Fournier 
found  in  two  hundred  and  forty-nine  cases  of  tabes  two  hundred  and 
thirty-one  in  which  there  was  undoubted  syphilis, — that  is,  ninety- 
three  per  cent.  Many  others  have  compiled  statistics  coinciding  for 
the  most  part  with  this  percentage. 

As  syphilitic  tabes  is  similar  in  symptoms  to  ordinary  tabes,  so  is 
it  similar  in  its  usual  incurability ;  when  it  is  once  firmly  estabhshed, 
potassium  iodide  and  mercury  often  have  no  effect ;  on  the  contrary, 
they  may  be  rather  deleterious. 

The  diagnosis  of  tabes  is  not  very  difficult  when  the  disease  is 
fully  developed,  but  to  be  able  to  recognize  it  in  an  incipient  stage 
and  find  a  clue  to  its  etiology  is,  though  most  difficult,  of  the  utmost 
importance.  In  this  early  stage,  cures  under  antisyphilitic  treatment 
are  possible ;  this  strengthens  the  theory  of  its  syphilitic  connection 
or  origin. 

The  premonitory  symptoms  of  ataxia  may  be  nothing  more  than 
pains  in  the  lower  extremities,  which  are  for  a  considerable  time  re- 


SYPHILIS   OF   THE   NEKVOUS   SYSTEM.  921 

garded  simply  as  rheumatic ;  they  have  not  the  characteristics  of  the 
osteocopic  pains.  Urinary  troubles  without  apparent  cause  are  also 
signs  of  great  value,  and  it  is  quite  common  to  see  associated,  in  addi- 
tion to  all  the  symptoms  of  ordinary  tabes,  a  few  other  manifestations 
of  an  irregular,  perhaps  cerebral,  type.  Mario  Bertolotti  notes  that 
the  Argyle  Robertson  pupil  may  be  indicative  of  syphilitic  meningitis, 
general  paresis,  meningomyelitis,  and  pseudobulbar  palsy,  and  that 
it  is  one  -of  the  earliest  symptoms  of  all  forms  of  syphilis  of  the  nervous 
system. 

SYPHILIS   OF  THE   NERVES. 

At  any  period  of  the  disease  syphihs  is  liable  to  attack  the  nerves 
or  the  ganglia. 

Syphilitic  degeneration  of  the  parenchyma  of  the  nerve  itself  is 
rare ;  the  process  usually  takes  place  in  the  net-work  of  connective 
tissue  between  the  fibres  and  in  the  sheaths  of  the  nerves.  But 
wherever  the  lesion  is  situated  in  the  nerve,  the  symptoms  are  vir- 
tually the  same,  and  manifest  themselves,  as  in  other  organic  neuroses, 
by  disturbances  of  sensation,  motion,  and  nutrition. 

The  sciatic  nerve  is  perhaps  the  most  frequently  affected,  al- 
though any  one  of  the  nerves  is  liable  to  attack.  The  pains  pro- 
duced by  these  lesions  are  not  to  be  confounded  with  the  rheuma- 
toid neuralgias  which  occur  early  in  the  secondary  stage,  and  which 
are  in  reality  only  slight  functional  disorders  and  not  the  result  of 
true  neuritis ;  nor  with  the  pain  caused  by  small  periosteal  tumors, 
such,  for  instance,  as  those  formed  upon  the  sternum  and  the  ribs. 

The  suffering  caused  by  syphilitic  neuritis  is  intense,  and  fre- 
quently accompanied  by  contractions  of  the  muscles,  paresis,  and 
paralysis.  The  early  sciaticas — those  occurring  at  the  beginning  of 
the  secondary  stage — are  readily  cured  by  specific  treatment,  and 
rarely  last  more  than  a  week  or  two ;  coming  on  later  in  the  disease 
and  accompanied  by  evidences  of  degeneration,  they  are  much  more 
serious,  and  are  then  probably  due  to  sclerosis  or  gumma  formation 
in  the  connective  tissue  and  substance  of  the  nerve. 

In  like  manner  neuralgias  of  the  occipital  and  cervical  nerves  are 
of  slight  import  in  the  early  secondary  stage,  but  when  occurring  in 
the  tertiary  period  they  are  to  be  regarded  as  grave  symptoms  of 
disease  of  the  cervical  vertebrae. 

Syphihs  not  uncommonly  attacks  the  cranial  nerves  and  the  nerves 
of  special  sense.  The  lesions  may  be  of  the  nerves  themselves,  or 
of  their  sheaths,  or  of  their  canals  of  exit  from  the  skull ;  or  the 
symptoms  tnay  be  due  to  the  presence  of  neighboring  gummata. 

In  any  event  there  will  probably  be  paralyses  or  possibly  con- 


922  GENITO-URIlSrAEY   DISEASES   AND   SYPHILIS. 

tractions  of  the  muscles  which  the  involved  nerves  supply.  Although 
the  symptoms  are  the  same  as  from  neuritis  dependent  upon  other 
causes,  a  history  of  syphilis  affords  sufficient  justification  for  assuming 
that  the  lesions  are  specific  and  for  treating  them  as  such.  If  they 
occur  at  a  period  remote  from  other  syphilitic  manifestations  they 
must  be  diagnosed  by  the  method  of  exclusion  or  by  applying  the 
therapeutic  test. 

The  earlier  the  symptoms  of  nerve-involvement  appear  in  the 
disease  the  more  favorable  is  the  prognosis. 

The  optic  nerve,  according  to  Charcot,  may  be  the  seat  of  fibrous 
metamorphosis  incident  to  parenchymatous  neuritis.  The  lesion  of 
the  optic  nerve  is  usually  a  phenomenon  of  late  appearance,  and 
depends  more  or  less  upon  cerebro-syphiloses. 

The  sense  of  smell  is  affected  when  pachymeningitis  of  tte  anterior 
cerebral  fossa  causes  pressure  upon  the  olfactory  lobes :  it  may  also 
be  impaired  by  extensive  destruction  of  the  bones  and  the  mucous 
membrane  of  the  nose. 

In  like  manner  the  auditory  nerve  is  affected  either  by  central 
lesion  or  by  destruction  of  its  bony  envelope. 

Of  all  the  cranial  nerves  the  motor  oculi,  or  third  pair,  is  the  one 
most  frequently  affected.  Paralysis  of  this  nerve  often  makes  its  ap- 
pearance early  in  the  secondary  stage,  but  is  then  only  a  transitory 
affection.  When  the  lesion  is  deep-seated  the  symptoms  will  be 
ptosis,  dilatation  of  the  pupil,  external  strabismus,  and  paralysis  of 
accommodation. 

Possibly  mydriasis  may  be  the  only  symptom  ;  this  has  been  found 
to  be  the  case  when  the  lesion  is  situated  near  the  lenticular  ganglion 
and  cuts  off  only  the  short  ciliary  branches  of  the  nerve. 

The  fourth  pair  is  rarely  affected. 

Lesions  of  the  fifth  pair  are  common,  and  are  manifested  by 
neuralgias  or  hypersesthesias  of  any  or  all  of  its  branches. 

Affections  of  the  sixth  pair  are  rare ;  they  are  accompanied  by 
diplopia,  convergent  strabismus,  and  orbital  neuralgia. 

The  seventh  pair  of  nerves  exhibits  a  peculiarity  in  that  it  is  so 
often  affected  early  in  the  disease,  at  times  within  a  few  weeks  of  the 
appearance  of  chancre. 

The  symptoms  vary  according  to  the  situation  of  the  lesion :  if 
it  is  situated  on  the  main  trunk  of  the  nerve  within  the  Fallopian 
canal,  or  beyond  it,  paralysis  of  the  face  is  the  only  symptom ;  if  it 
is  situated  within  the  skull,  the  usual  symptoms  of  intracranial  lesion 
— headache,  vertigo,  aphasia,  convulsions,  etc. — are  also  pj-esent. 

The  other  cranial  nerves  are  rarely  affected. 


SYPHILIS   OF   THE   EYE.  923 


SYPHILIS    OF   THE    EYE. 


Chancre  may  develop  on  the  eyeUd  or  on  the  conjunctiva.  Be- 
ginning as  a  pimple,  the  lesion  gradually  develops  into  a  characteristic, 
saucer-shaped  ulceration,  with  rounded  edges  and  indurated  base. 

Secondary  syphilis  may  appear  upon  the  eyehds,  as  well  as  gum- 
mata  of  the  skin  and  so-called  tertiary  ulcers. 

Syphilitic  tarsitis  is  an  inflammation  of  the  tarsus,  which  produces 
great  thickening  of  the  lids,  and  in  some  instances  is  due  to  a  diffuse 
gummatous  infiltration.  More  rarely  it  is  acute,  and  then  must  not  be 
mistaken  for  an  ordinary  strumous  inflammation  of  the  ciliary  border, 
from  which  it  is  to  be  distinguished  by  the  thickening  and  induration 
of  the  tarsus. 

Syphilitic  conjunctivitis  has  been  described  in  a  few  instances,  the 
appearances  being  somewhat  analogous  to  those  of  granular  lids,  the 
disease  yielding,  however,  only  to  antisyphihtic  remedies. 

Syphilitic  periostitis  may  attack  the  orbital  margins  either  in  a 
gummatous  or  in  a  sclerosing  form.  When  the  orbital  walls  are  in- 
volved behind  the  capsule  of  Tenon,  the  type  is  almost  always  gum- 
matous. The  symptoms  are  then  pain,  worse  at  night,  restriction  in 
the  mobility  of  the  globe,  squint,  and  diplopia.  As  complications 
there  may  be  optic  neuritis  and  inflammation  of  the  cornea. 

Caries  of  the  margin  of  the  orbit  is  not  uncommon  in  syphilis, 
usually  as  the  result  of  pre-existing  periostitis. 

Syphilis  of  the  Lachrymal  Apparatus. — Occasionally  the 
lachrymal  gland  becomes  enlarged  and  indurated  as  the  result  of 
syphilis,  and  hypertrophy  of  this  body,  appearing  as  an  indurated 
lobulated  tumor,  having  its  situation  in  the  upper  and  outer  part  of 
the  orbit,  should  always  be  given  careful  antisyphilitic  treatment 
before  surgical  measures  are  adopted. 

Occasionally  a  lachrymal  abscess  forms  in  children  above  the  in- 
ternal palpebral  ligament  and  external  to  the  sac  itself:  hence  the 
name  prelachrymal  abscess ;  it  is  usually  due  to  inherited  syphihs. 

The  lachrymal  sac  and  nasal  duct  may  become  obstructed  through 
periostitis  and  caries  of  the  lachrymal  bone  or  the  pressure  of  gum- 
matous deposits.  The  lachrymal  apparatus  in  its  entirety  is  singularly 
free  from  manifestations  of  syphilis. 

Syphilitic  Affections  of  the  Cornea. — Interstitial  Keratitis 
(syphilitic,  inherited,  specific,  parenchymatous,  or  diffuse  keratitis). — 
This  is  a  chronic  inflammation  of  the  whole  thickness  of  the  cornea,  the 
membrane  gradually  passing  into  a  condition  of  universal  thick  haziness, 
associated  with  vascularization,  but  almost  always  without  ulceration. 


924  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

Causes. — Inherited  syphilis  is  tlie  cause  in  between  sixty  and  seventy 
per  cent,  of  the  cases.  Very  rarely  perfectly  typical  examples  appear 
with  acquired  syphilis.     It  is  described  under  hereditary  syphilis. 

Punctate  keratitis,  characterized  by  the  deposition  of  opaque  dots 
arranged  in  a  triangular  manner  upon  the  posterior  elastic  lamina  of 
the  cornea,  is  usually  an  indication  of  affections  of  the  iris,  choroid, 
and  vitreous,  but  may  also  appear  both  with  and  without  iritis,  and 
as  a  syphilitic  inflammation.  It  occurs  in  the  late  or  gummatous 
period  of  syphilis,  but  i3  seen  also  in  children  before  puberty  as  one 
of  the  forms  of  inherited  syphilis.  The  treatment  is  the  same  as  that 
described  under  interstitial  keratitis. 

Syphilis  of  the  Sclera. — A  certain  number  of  cases  of  scleritis 
and  episcleritis — that  is,  inflammation  of  the  sclera  itself  or  its  over- 
lying tissue — have  been  ascribed  to  acquired  syphilis  and  yielded  to 
the  ordinary  remedies.  So,  also,  in  the  late  stages  of  syphilis,  a  true 
gummatous  scleritis  may  develop,  characterized  by  the  formation  of 
yellowish-brown  and  semi-translucent  nodules  on  this  membrane. 

Syphilis  of  the  Iris. — Fifty  per  cent,  of  all  cases  of  iritis  are 
syphilitic,  and  are  frequently  associated  with  choroiditis. 

There  are  four  distinct  varieties  of  the  affection. 

1.  Syphilitic  Plastic  Iritis. — This  may  occur  in  the  early  stages 
of  general  syphilis,  usually  between  the  second  and  the  ninth  month 
after  the  initial  lesion,  and  is  characterized  by  the  ordinary  symptoms 
of  iritis, — namely,  fine  pericorneal  injection,  contracted,  sluggish,  or 
immobile  pupil,  discolored  iris,  abnormal  reaction  to  a  mydriatic,  slight 
tenderness  on  pressure,  the  formation  of  attachments  between  the 
margin  of  the  iris  and  the  capsule  of  the  lens  (posterior  synechiae), 
and  severe  pain  in  the  brow  and  head,  worse  at  night. 

The  symptoms  do  not  differ  from  those  of  a  simple  iritis  from 
other  cause,  and  are  of  themselves  not  characteristic  of  the  disease, 
yet  the  lesions  are  due  to  the  syphilitic  taint  and  yield  to  the  ordinary 
constitutional  remedies  and  local  measures. 

2.  Syphilitic  parenchymatous  iritis,  or  true  syphilitic  iritis,  belongs 
to  the  parenchymatous  variety  of  the  affection,  being  an  accompani- 
ment of  secondary  syphihs,  and  is  characterized  by  a  deposit  of  yel- 
lowish-red nodules  on  the  ciliary  or  the  pupillary  border  of  the 
inflamed  iris,  comparable  to  the  papules  and  condylomata  of  the  stage 
at  which  it  occurs,  and  hence  called  iritis  papulosa  or  condylomatous 
iritis.  These  small  nodules  vary  in  number  from  one  to  four,  and  are 
gradually  absorbed  under  treatment,  leaving  faint  scars  in  the  iris- 
tissue  to  mark  their  former  situation.  Sometimes  instead  of  distinct 
nodules  there  are  local  swellings  in  the  iris-tissue,  the  membrane 


SYPHILIS   OF   THE   EYE.  925 

being  attached  at  these  situations  by  broad  and  moderately  soft 
synechise  to  the  capsule  of  the  lens,  causing  fixed  distortion  of  the 
pupil,  often  "  umbrella  "  iris,  and  impairment  or  loss  of  vision. 

3.  Gummatous  iritis — gumma  of  the  iris — occurs  in  the  late  or 
tertiary  stages  of  syphilis,  and  is  characterized  by  the  development 
of  large  yellowish  nodules,  usually  on  the  ciliary  border  of  the  iris, 
and  strongly  analogous  to  gummata  elsewhere  in  the  body. 

Occasionally  at  this  late  stage  an  iritis  unassociated  with  nodules 
appears,  somewhat  resembling  the  plastic  type  of  the  disease,  and 
probably  the  relapse  of  a  plastic  iritis  which  occurred  in  an  early 
stage,  owing  to  a  failure  in  the  absorption  of  the  original  synechise. 

4.  Serous  iritis  (more  properly,  serous  cyclitis),  characterized  by 
a  serous  or  sero-plastic  exudate,  deepening  of  the  anterior  chamber, 
slight  dilatation  of  the  pupil,  haziness  of  the  cornea,  and  opaque  dots 
on  its  posterior  elastic  membrane  arranged  in  a  triangular  manner,  is 
an  unusual  variety  of  iritis  as  the  result  of  acquired  syphilis  in  the 
secondary  stage,  although  common  from  many  other  causes. 

Prognosis. — The  prognosis  of  the  various  types  of  syphilitic  iritis 
is  good,  provided  the  cases  are  seen  early,  before  firm  adhesions 
form  and  much  exudation  pours  out  into  the  pupillary  space,  causing 
either  its  occlusion  or  its  exclusion.  When  thoroughly  cured,  relapses 
are  infrequent.  Commonly  both  eyes  are  attacked,  one  a  little  later 
than  its  fellow  ;  occasionally  the  onset  is  simultaneous. 

Treatment. — This  should  consist  in  the  free  use  of  atropine  drops, 
four  grains  to  the  ounce,  hot  compresses  and  leeching  the  temple  to 
relieve  pain  and  enhance  the  action  of  the  atropine,  and  the  persistent 
use  of  such  antisyphilitic  remedies  as  are  indicated  by  the  stage  at 
which  the  iritis  appears.  In  stubborn  cases,  and  especially  in  gumma- 
tous iritis,  subconjunctival  injections  of  bichloride  of  mercury  may  be 
used  with  benefit.  Success  depends  upon  beginning  the  treatment 
early  enough  to  tear  loose  the  synechise  by  the  use  of  atropine, 
which,  except  in  the  cases  of  serous  iritis  where  there  is  a  tendency 
to  rise  of  intra-ocular  tension,  must  be  vigorously  used  until  all 
signs  of  irritation  have  passed  away  and  a  perfectly  round  pupil  is 
obtained. 

Inherited  syphiHs  may  also  produce  iritis,  the  disease,  character- 
ized by  much  exudation  and  rapid  occlusion  of  the  pupil,  usually 
appearing  between  the  ages  of  two  and  fifteen  months,  and  being 
very  much  more  frequent  in  girls  than  in  boys.  It  is  probable  that 
all  iritis  occurring  in  young  children  is  due  to  syphilis. 

Subacute,  chronic,  and  so-called  quiet  iritis  may  also  be  caused 
by  syphilis,  the  latter,  as  its  name  implies,  being  unassociated  with 


926  GENITO-UKINAEY   DISEASES   AND   SYPHILIS. 

much  pain  or  ciliary  congestion,  the  progressive  dimness  of  vision 
usually  leading  to  its  discovery. 

Syphilis  of  the  Oihary  Body. — Independently  of  the  fact  that 
this  structure  is  commonly  involved  in  all  the  severe  types  of  in- 
flammation of  the  iris,  forming  the  so-called  irido-cyclitis,  and  that 
serous  iritis  is  really  a  manifestation  of  inflammation  of  the  ciliary 
body,  syphilis  strictly  confined  to  this  structure  is  uncommon.  In  a 
few  instances,  however,  gummata  thus  located  have  been  described. 

The  treatment  of  cyclitis  of  syphilitic  origin,  or,  more  properly, 
irido-cyclitis,  does  not  differ  from  that  of  iritis. 

Syphilis  of  the  Choroid,  Retina,  and  Optic  Nerve.— The 
most  important  lesions  of  these  structures,  discoverable  only  with  the 
ophthalmoscope,  are  the  following : 

Deep  choroiditis,  characterized  in  its  diffuse  exudative  variety  by 
yellowish-white  plaques,  going  on  later  to  absorption,  heaping  of  pig- 
ment, and  atrophy  of  the  retina  (choroido-retinitis),  and  in  its  dissem- 
inated variety  by  the  formation  of  numerous  round  and  oval  spots  in 
the  fundus  ocuh,  which  have  a  characteristic  punched-out  look  and 
the  margins  of  which  are  bordered  with  black  pigment.  In  the  later 
stages  opacities  in  the  vitreous  humor  are  common,  and  atrophy  of 
the  optic  nerve  may  take  place.  Vision  is  often  seriously  affected, 
especiahy  if  the  region  of  the  macula  is  involved. 

The  various  types  of  choroiditis  which  are  due  to  acquired  syphi- 
hs  appear  from  six  months  to  two  years  after  the' initial  lesion; 
sometimes  ten  years  elapse  before  their  appearance. 

Choroiditis  of  similar  type  may  be  due  to  inherited  syphilis,  and 
develops  between  the  sixth  month  and  the  third  year  of  Hfe.  The 
treatment  consists  in  the  exhibition  of  the  usual  antisyphilitic  reme- 
dies. The  subconjunctival  injections  of  sublimate  are  said  to  be 
especially  efficacious. 

There  are  a  number  of  other  types  of  choroiditis  which  probably 
depend  upon  syphilis,  but  that  named  is  the  most  important. 

SYPmLiTic  RETINITIS  occurs  in  various  types.  The  first  variety, 
ordinarily  called  choroido-retinitis,  is  really  a  disease  of  the  choroid. 
The  most  important  symptoms  are  opacity  of  the  vitreous  (syphilitic 
hyalitis),  usually  in  the  form  of  dust-like  particles ;  loss  of  trans- 
parency of  the  retina  around  the  head  of  the  optic  nerve,  which  is 
unduly  hyperaemic ;  and  numerous  yellow  or  white  spots  of  exuda- 
tion bounded  by  pigment  lying  beneath  the  vessels  of  the  retina. 
Vision  is  much  affected,  especially  in  dim  lights,  the  field  of  vision  is 
contracted,  and  the  patient  complains  of  shimmerings,  spots,  circles, 
dancing  lights,  and  distortion  of  objects. 


SYPHILIS   OF    THE    EYE.  927 

Sometimes  the  disease  is  more  truly  located  in  the  retina,  which 
becomes  affected  with  a  gray  opacity,  the  optic  nerve  entrance  being 
yellowish  red  in  color,  while  floating  opacities  arise  in  the  vitreous ; 
occasionally  there  are  hemorrhages. 

Of  an  unusual  type  and  one  belonging  to  the  late  manifestations 
is  a  central  retinitis,  located  largely  in  the  macular  regions,  and  char- 
acterized by  the  appearance  of  numerous  yellow  or  yellowish-white 
spots  and  pigment-dots. 

Retinitis  may  occur  both  in  congenital  and  in  acquired  syphihs. 
In  the  acquired  form  it  appears  usually  from  one  to  two  years  after 
infection,  but  sometimes  as  early  as  the  sixth  month.  Generally  both 
eyes  are  involved. 

In  the  hereditary  disease  it  arises,  like  choroiditis,  between  the 
sixth  month  and  the  third  year  of  life. 

The  treatment  consists  in  the  exhibition  of  the  ordinary  anti- 
syphilitic  remedies,  which  should  be  vigorously  pushed  in  order  to 
prevent  secondary  changes  in  the  optic  nerve  and  consequent  blind- 
ness. The  eye  should  be  protected  with  dark  glasses,  and  the  accom- 
modation paralyzed  with  a  weak  solution  of  atropine. 

Syphilitic  optic  neuritis,  characterized  by  swelling  of  the  nerve- 
head,  distention  of  the  veins,  which  become  darker  in  color  and  tor- 
tuous, and  hemorrhages  upon  the  swollen  papilla  or  in  its  immediate 
neighborhood,  may  be  caused  by  the  formation  of  an  intracranial 
product,  for  example,  a  gumma,  or  may  develop  as  an  essential  sign 
of  syphilis. 

Rapid  mercurialization  should  be  practised,  to  be  followed  later 
by  the  iodides,  and  if  the  exudation  is  quickly  absorbed  the  prognosis 
as  to  vision  may  be  good ;  otherwise  the  tissues  are  strangled,  and 
there  results 

Atrophy  of  the  Optic  Nerve. — In  addition  to  this  consecutive 
atrophy  of  the  optic  nerve  the  result  of  a  syphilitic  neuritis,  a  primary 
atrophy  occurs,  as  well  as  the  various  types  of  degeneration  of  the 
nerve-head,  which  are  due  to  general  causes  resulting  from  syphilis, 
for  example,  locomotor  ataxia. 

The  usual  symptoms  of  optic  nerve  atrophy  are  progressive  loss 
of  vision,  ever-increasing  restriction  of  the  field  of  vision,  and  the 
ophthalmoscopic  appearances  of  atrophy, — namely,  pallor  of  the 
disk,  absence  of  capillaries,  and  shrinking  of  the  size  of  the  vessels. 

Syphilitic  Palsies  of  the  External  Ocular  Muscles. — The 
most  frequent  cause  of  paralysis  of  the  external  ocular  muscles  is 
syphilis,  fully  one-half  of  the  cases  having  this  origin.  The  usual 
lesion  is  an  inflammation  or  gummatous  change  affecting  the  nerve 


928  GENITO-URINAEY   DISEASES    AND   SYPHILIS. 

at  the  base  of  the  brain,  or  in  the  orbit,  or  there  may  be  disease  of 
the  nuclei  of  the  nerves  or  of  the  brain  in  their  immediate  vicinity,  or, 
finally,  the  lesions  may  exist  in  the  third  ventricle,  in  the  aqueduct 
of  Sylvius,  or  in  the  fourth  ventricle.  Syphilitic  paralysis  is  usually 
but  not  always  one  of  the  late  manifestations  of  syphihs.  The  oculo- 
motor nerve  is  the  one  most  frequently  affected.  The  involvement  is 
often  a  forerunner  of  tabes  or  general  paralysis. 

In  rare  instances  there  is  paralysis  of  the  ocular  muscles  as  the 
result  of  inherited  syphilis. 

The  usual  symptoms  of  palsy  of  the  ocular  muscles  are  present, — 
namely,  double  vision,  strabismus,  limitation  of  movement  in  the 
direction  of  the  affected  muscles,  vertigo,  and  an  altered  position  of 
the  carriage  of  the  head,  which  is  apt  to  be  turned  in  the  direction  in 
w^hich  the  patient  is  least  troubled  by  the  double  images. 

Ophthalmoplegia  is  a  term  used  to  characterize  a  loss  of  pov^er  in 
one  or  more  of  the  eye-muscles,  which  gradually  increases  and  in- 
volves other  muscles  until  all  of  them  may  be  paralyzed.  This  may 
be  caused  by  hereditary  and  also  by  constitutional  syphilis. 

In  addition  to  the  paralysis  of  the  external  muscles  of  the  eye 
there  are  various  conditions  of  the  pupil  and  ciliary  body  which  arise 
under  the  influence  of  syphihs ;  thus,  if  the  oculo-motor  is  paralyzed 
and  those  branches  which  supply  the  iris  and  the  ciliary  body  are 
affected,  there  will  be  dilatation  of  the  pupil  and  loss  of  accommoda- 
tion. Occasionally  there  is  a  wide  dilatation  of  one  pupil  without 
affection  of  the  ciliary  body,  and  inequality  of  the  pupils  may  arise  in 
the  course  of  a  focal  syphihtic  brain-lesion.  The  treatment  of  these 
ocular  palsies,  both  external  and  internal,  demands  the  use  of  mercury 
and  ascending  doses  of  potassium  iodide. 

SYPHILIS   OF   THE   EAR. 

The  auricle  and  meatus  may  exhibit  any  of  the  characteristic 
lesions  of  constitutional  syphilis. 

In  the  secondary  stage  of  the  disease  dry  or  moist  papules  are 
observed.  These  when  they  involve  the  meatus  are  prone  to  ulcerate 
or  to  form  papular  overgrowths,  accompanied  by  marked  purulent 
secretion.  As  a  result  of  free  suppuration  and  blocking  of  the  canal, 
perforation  of  the  drum  and  suppurative  disease  of  the  middle  ear 
may  result.  Condylomata  are  the  most  frequent  specific  lesions  of 
the  meatus. 

Gummata  of  the  external  auditory  meatus  appear  in  the  form  of 
moderate-sized  chronic  abscesses.  These  are,  however,  extremely  rare. 

The  middle  ear  if  involved  shows  the  changes  incident  to  catarrhal 


SYPHILIS   OF   THE   KESPIRATOKY   TRACT.  929 

inflammation.  This  is  usually  secondary  to  suppurating  lesions  of  the 
throat. 

The  pharyngeal  opening  of  the  Eustachian  tube  is  frecjuently  the 
seat  of  chancre, — the  infection  being  carried  by  the  Eustachian  cath- 
eter,— of  mucous  patches,  and  of  gummata.  Cicatricial  contraction 
following  these  lesions  may  completely  block  the  Eustachian  tube. 
Syphilitic  otitis  media  may  assume  the  suppurative  or  the  sclerosing 
form.  Meningitis,  sinus  thrombosis,  facial  palsy,  and  the  other  com- 
pHcations  of  non-specific  middle-ear  disease  may  develop.  Local 
treatment  is  of  cardinal  importance. 

The  labyrinth  is  exceptionally  attacked  in  the  early  secondary 
stage  of  the  disease ;  usually  this  is  a  late  tertiary  manifestation,  and 
it  is  much  more  frequent  in  congenital  than  in  acquired  syphilis. 
Tinnitus,  vertigo,  and  sudden  onset  of  deafness  are  the  chief  symp- 
toms. 

Diagnosis. — This  is  founded  on  the  history  of  syphilis  and  the 
absence  of  other  discoverable  cause  for  disturbance  of  hearing.  The 
rapid  onset  of  deafness  is  also  characteristic.  The  prognosis  always 
should  be  guarded.  The  most  severe  cases  sometimes  recover 
promptly  as  the  result  of  specific  treatment ;  the  mildest  cases  may 
remain  uninfluenced  by  mercury  and  the  iodides. 

Treatment. — This  when  the  meatus  is  involved  should  comprise 
thorough  cleansing,  the  use  of  astringents,  and  the  application  of 
caute rants  to  ulcerating  spots.  Extensive  overgrowths  and  polypi 
should  be  detached  by  snaring  or  curetting. 

When  the  labyrinth  is  involved  the  specific  treatment  should  be 
pushed  to  its  extreme  limit.  The  prognosis  is  unfavorable  in  these 
cases. 

SYPHILIS   OF  THE   RESPIRATORY  TRACT. 

Syphilis  of  the  Nose. — Primary  lesions  of  the  nose  are  ex- 
tremely rare.  A  few  cases  are  recorded  due  to  the  use  of  infected 
instruments,  and  in  some  instances  the  disease  has  arisen  from 
unnatural  practices. 

Secondary  manifestations,  in  the  form  of  moist  papules,  fre- 
quently appear  about  the  nostrils. 

Gummata  involving  the  external  nose  exhibit  a  predilection  for 
the  wings,  the  point,  the  cartilaginous  septum,  and  the  neighborhood 
of  the  tear-ducts.  These  gummata,  beginning  first  in  the  subcu- 
taneous tissues,  extend  in  depth,  involving  the  bones  or  cartilages 
beneath.  When  there  is  also  gummatous  infiltration  of  the  walls  of 
the  nasal  cavity  marked  deformity  results. 

59 


930  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

Syphilis  of  the  Nasal  Cavities. 

1.  Syphilitic  rhinitis. 

Acute. 

Chronic ;  hypertrophic, 
atrophic. 

2.  Gummata. 

Nodular. 
Infiltrating. 

Acute  Syphilitic  Rhinitis. — ^Acute  rhinitis,  one  of  the  most  fre- 
quent secondaries  of  hereditary  syphilis,  is  comparatively  rare  in  the 
acquired  form  of  the  disease.  It  begins  much  as  does  a  simple 
catarrhal  rhinitis,  and  at  first  cannot  be  distinguished  from  this  affec- 
tion ;  later  it  develops  one  of  the  chief  characteristics  of  syphilis, — 
polymorphism.  If  the  nasal  cavities  are  examined,  the  inflammation 
v^ill  be  found  to  vary  in  intensity  even  in  different  parts  of  the  same 
nostril.  Ecchymoses,  abrasions,  superficial  ulcerations,  and  at  times 
mucous  patches  may  be  seen,  particularly  on  the  septum  and  the 
lovs'er  turbinals.  The  posterior  nares  are  at  first  but  slightly  in- 
volved ;  later  they  show  the  characteristic  thickening,  hyperaemia,  and 
dusky  redness  of  acute  inflammation  ;  by  this  time  deeper  lesions 
will  have  developed  anteriorly. 

Acute  specific  rhinitis  differs  from  the  catarrhal  inflammation  by 
persisting  in  spite  of  careful  treatment  and  by  giving  blood-stained 
discharge  or  hemorrhage  not  at  the  beginning  of  the  attack,  but  later 
when  erosions  and  ulcers  have  developed.  Usually  the  accessory 
nasal  cavities  are  but  slightly  involved.  Hypertrophic  and  ultimately 
atrophic  rhinitis  may  be  the  direct  sequelae  of  the  acute  inflammation. 

Hypertrophic  rhinitis  presents  a  spongy,  swollen,  polypoid  mucous 
membrane,  so  thickened  that  practically  no  breathing-space  is  left. 
Ulceration  is  often  present,  particularly  on  the  nasal  septum,  the 
lesion  here  being  sharply  defined  and  exhibiting  an  unhealthy,  readily 
bleeding  surface. 

The  secretion  is  abundant,  often  blood-stained,  and  stinking.  The 
mucous  membrane  of  the  maxillary,  frontal,  and  sphenoidal  sinuses 
may  become  involved,  causing,  from  retained  secretions,  severe  head- 
ache or  neuralgic  pain,  and  finally  abscess.  Since  the  mucous  mem- 
brane is  closely  applied  to  the  nasal  bones  and  cartilages,  particularly 
that  overlying  the  lower  turbinals,  perichondritis,  periostitis,  ostitis, 
caries,  and  necrosis  generally  compHcate  chronic  specific  rhinitis. 
Bone-  or  cartilage-involvement  commonly  gives  rise  to  no  subjective 
symptoms  beyond  deformity  and  blood-stained  discharge,  complete 
perforation  of  the  septum  often  taking  place  without  the  patient  being 


SYPHILIS   OF   THE    EESPIRATORY    TRACT.  931 

aware  of  it.  The  nostrils  may  be  so  effectually  closed  that  mouth- 
breathing,  with  its  evil  consequences,  results.  The  sense  of  smell 
may  be  lost,  and  the  tear-ducts  may  be  chronically  inflamed  or  may 
be  obliterated. 

Atrophic  rhinitis  follows  the  hypertrophic  inflammation,  or  may 
be  caused  by  the  wasting  which  follows  gummatous  infiltration.  The 
turbinals  are  often  involved  in  the  atrophic  process,  and  may  be  cov- 
ered by  thick  offensive  crusts  concealing  ulcerations.  The  abnormal 
roominess  of  the  nasal  cavities,  the  thin,  bloodless,  scar-like  mucous 
membrane,  and  the  fetor  are  characteristic  of  atrophic  rhinitis, 
whether  it  be  specific  or  not. 

Diagnosis. — The  diagnosis  of  chronic  syphilitic  rhinitis  must  be 
based  on  a  specific  history  or  associated  signs  of  the  disease,  since  it 
does  not  differ  from  the  catarrh  observed  in  non-syphilitics,  particu- 
larly in  those  of  a  strumous  diathesis. 

GuMMATA. — These  lesions  when  they  are  developed  in  the  nasal 
cavity  are  usually  late  tertiaries.  If  not  treated  promptly  and  ener- 
getically they  produce  conspicuous  and  irremediable  deformity  of  the 
external  nose.  They  appear  as  distinct  nodules  or  as  diffuse  infil- 
trations. 

The  GUMMATOUS  NODULE  attacks  by  preference  the  cartilaginous 
septum  and  the  floor  of  the  nasal  canals.  Occasionally  it  is  found  on 
or  near  the  alar  cartilages.  It  is  usually  single,  grows  slowly,  rarely 
reaching  the  size  of  a  small  cherry,  and  is  often  associated  with  syph- 
ilitic rhinitis  or  gummatous  infiltration.  Though  painless  in  its  course, 
if  untreated  it  commonly  erodes  the  underlying  cartilage  or  bone. 
The  resulting  deformity  is  much  less  than  that  incident  to  the  break- 
ing down  of  gummatous  infiltration.  Gummata  growing  from  the 
mucous  membrane  covering  the  alar  cartilages  perforate  the  latter 
and  open  into  the  nasal  cavity.  When  they  originate  in  the  cartilage 
itself  the  j)erfo ration  may  be  external.  In  the  latter  case  ulceration 
may  extend  to  the  lower  border  of  the  cartilage,  and  be  followed  by 
a  pecuHar  pinching  deformity,  which  may  be  symmetrical. 

Gummata  on  the  floor  of  the  nose  are  rarely  detected  until  they 
have  broken  down  and  formed  ulcers,  or  until  they  have  opened  into 
the  mouth.  The  upper  portion  of  the  nasal  cavity  is  rarely  attacked 
by  the  nodular  gumma. 

Gummatous  infiltration  is  the  affection  which  causes  the  most 
marked  nasal  deformities.  It  involves  both  the  mucous  membrane  and 
the  underlying  periosteum  and  perichondrium,  and  extends  rapidly 
both  in  depth  and  in  surface.  Because  of  rapid  interference  with 
blood-supply,  it  is  prone  to  slough,  the  destructive  process  extending 


932 


GENITO-UPvIlSrAKY    DISEASES   AND   SYPHILIS. 


wide  of  the  original  infiltrate.  Bones  and  cartilages  rapidly  necrose ; 
there  may  be  complete  destruction  of  all  the  cartilages  and  the  bones 
immediately  surrounding  the  nasal  space.  Necrosis  of  the  cribriform 
plate  of  the  ethmoid  and  the  vomer,  by  taking  away  the  support  of 
the   nasal   bones,   allows   them   to  sink,  even  though  they  are  not 


Fig.  309. 


Gummatous  ulceration  destroying  tlie  nose. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 

involved,  producing  the  so-called  saddle-back  nose.  This  is  more 
commonly  due  to  associated  necrosis  of  these  bones,  which  may  cause 
complete  destruction  of  the  nose.  (Fig.  309.)  From  extension  of 
the  inflammation  the  ethmoid,  the  sphenoid,  the  palatal  bone,  and 


SYPHILIS    OF    THE    KESPIRA.TORY   TRACT.  933 

the  superior  niaxillaries,  particularly  the  palatal,  nasal,  and  alveolar 
processes,  may  become  extensively  diseased. 

Diagnosis. — Gummata  and  gummatous  infiltrations,  involving  the 
mucous  membrane  of  the  nose,  are  characterized  by  ordinary  catarrhal 
symptoms,  but  differ  from  catarrh  in  the  fact  that  the  symptoms  are 
constantly  referred  to  the  same  diseased  area.  When  ulceration 
becomes  deep,  involving  bones,  and  before  this  in  hypertrophic  and 
atrophic  rhinitis,  the  discharge  is  extremely  offensive.  On  exami- 
nation the  destructive  process  is  often  found  to  be  wide-spread. 
Rounded  ulcers,  often  covered  with  thick  crusts,  mark  the  position 
where,  on  probing,  dead  bone  is  detected.  As  a  result  of  gummatous 
involvement  of  the  cribriform  plate,  lethal  inflammation  may  extend 
to  the  meninges  of  the  brain. 

In  the  early  stages,  where  there  is  simply  beginning  infiltration, 
the  symptoms  and  lesions  are  so  like  those  of  chronic  catarrh  that 
differential  diagnosis  may  be  impossible.  The  history  of  the  case,  the 
presence  of  possibly  specific  lesions  resisting  the  ordinary  catarrhal 
treatment,  and  finally  the  therapeutic  test,  should  decide  this  question 
before  destruction  of  bone  has  taken  place. 

When  perforation  of  the  septum  is  found  the  disease  is  almost 
certainly  syphilitic,  though  tuberculous  lesions  may  produce  the  same 
result. 

Syphilitic  involvement  of  the  olfactory  nerves,  commonly  due  to 
pachymeningitis  of  the  base,  may  cause  anosmia. 

Treatment  consists  in  the  internal  administration  of  specifics  and 
in  local  cleanliness,  accomplished  by  antiseptic  and  stimulating  sprays 
and  vapors.  Exceptionally  the  bone-lesions  are  premature, — i,€.,  they 
complicate  secondary  syphilis  ;  mercury  should  then  be  combined  with 
the  iodides.  When  these  lesions  are  distinctly  gummatous  in  type, — 
and  under  such  circumstances  they  are  nearly  always  late  tertiaries, — 
the  iodides  form  the  basis  of  treatment,  supplemented  by  mercury, 
administered  preferably  by  inunctions.  When  dead  bone  is  found  it 
should  be  removed.  This  is  accomplished  under  ether  by  means  of 
the  finger  of  the  surgeon  aided  by  a  curette.  Bleeding  is  often  pro- 
fuse, but  is  readily  controlled  by  packing.  Following  this  the  whole 
nasal  cavity  must  be  cleaned  every  two  hours  with  sprays,  the 
first  containing  hydrogen  peroxide  twenty-five  per  cent.,  the  second 
dilute  solutions  of  thymol,  or  Dobell's  solution,  or  other  disinfectants 
and  antiseptics.  Insufflations  of  iodoform  and  iodol  may  be  service- 
able after  the  cleansing  spray.  When  a  small  portion  of  bone  is 
necrotic  it  is  safe  to  wait  until  this  is  loosened  before  attempting  to 
remove  it,  at  the  same  time  pushing  the  constitutional  treatment. 


934  GENITO-URINAEY   DISEASES   AND   SYPHILIS. 

For  the  deformity  of  the  nose  which  sometimes  results  from  cica- 
tricial contraction  following  extensive  necroses,  plastic  operations  of 
various  kinds  are  indicated.  Perhaps  the  most  satisfactory  from  a 
cosmetic  stand-point  is  the  insertion  of  an  artificial  bridge  of  gold, 
silver,  or  celluloid.  Over  this  the  loosened  skin  is  drawn  by  the  per- 
cutaneous suture.  When  there  is  not  enough  healthy  tissue  for  this 
procedure,  the  fitting  on  of  an  artificial  nose  is  advisable. 

Syphilis  of  the  Larynx. — Secondary  lesions  of  the  larynx 
appear  either  as  a  general  erythema,  not  distinguishable  from  that 
incident  to  cold  or  irritation,  or  as  mucous  patches,  which  are  mostly 
found  on  the  aryepiglottic  folds,  the  vocal  bands,  the  arytenoid  car- 
tilages, and  the  borders  of  the  epiglottis.  These  papules  are  some- 
times converted  into  superficial  erosions,  but  usually  yield  quickly  to 
constitutional  treatment,  leaving  no  trace,  save  at  times  alteration  of 
the  voice,  due  to  shght  thickening  of  the  mucous  membrane.  Very 
exceptionally  these  erosions  become  true  ulcers,  closely  simulating 
those  incident  to  gumma,  except  that  they  are  not  so  deep  nor  so 
destructive. 

Tertiary  lesions  may  be  expressed  in  the  form  of  a  diffuse  gum- 
matous infiltration  or  circumscribed  gumma. 

Diffuse  gummatous  infiltration  usually  attacks  the  epiglottis,  the 
vocal  cords,  and  the  posterior  wall  of  the  larynx.  The  mucous  mem- 
brane is  reddened  and  thickened,  and  there  is  ill-defined,  wide-spread 
infiltration  of  the  surrounding  tissues.  If  ulceration  takes  place  it  is 
generally  superficial,  though  a  large  surface  may  be  involved. 

Symptoms. — The  symptoms  are  due  to  disturbance  of  function  in- 
cident to  infiltration.  There  is  little  or  no  pain.  Until  the  voice  be- 
comes husky  the  patient's  attention  is  not  markedly  attracted  to  the 
throat.  Very  slowdy  progressing  ulceration  and  subsequent  cicatricial 
contraction  produce  marked  alterations  in  the  voice  and  may  obstruct 
breathing.  Exceptionally  there  is  immediate  total  aphonia,  followed 
later  by  partial  stenosis,  with  the  constitutional  symptoms  dependent 
upon  dyspncea. 

Diagnosis. — This  is  founded  upon  the  discovery  of  a  thickened, 
often  superficially  ulcerated  area,  without  associated  diseases  of  the 
lungs,  and  with  a  preceding  history  of  syphilis  and  often  other  mani- 
festations of  the  disease. 

Tuberculous  laryngitis,  the  only  affection  with  which  it  is  liable 
to  be  confounded,  is  hardly  ever  encountered  in  conjunction  with 
healthy  lungs. 

Circumscribed  gummata  involve  by  preference  the  epiglottis,  the 
aryepiglottic  folds,  the  true  and  false  vocal  cords,  and  the  posterior 


SYPHILIS   OF   THE   EESPIEATOKY   TRACT. 


935 


wall  of  the  larynx.  At  first  they  appear  as  rounded  elevations,  the 
mucous  covering  of  which  is  thickened ;  later  softening  takes  place 
and  deep  destructive  ulcerations  are  formed,  ultimately  resulting  in 
cicatricial  contraction,  which  seriously  interferes  with  the  function 
of  the  larynx.  During  the  ulcerating  stage  acute  CEdema  sometimes 
develops  and  threatens  death  from  suffocation. 

Symptoms. — The  symptoms  are  much  the  same  as  those  of  diffuse 
gummatous  infiltration,  except  that  the  discharge  is  more  profuse, 
pain  and  tenderness  are  more  frequently  noted,  and  the  functional 
disturbances  are  more  marked. 

Diagnosis. — This  is  founded  on  laryngeal  inflammation  associated 
with  nodules  and  ulcers  and  the  existence  of  a  history  and  other  signs 
of  syphilis. 

In  distinguishing  these  lesions  from  those  of  tuberculosis  it  must  be 
remembered  that  the  mucous  membrane  surrounding  syphilitic  ulcers 
is  practically  normal  in  color  or  congested,  not  pale.  The  develop- 
ment of  the  gummatous  infiltration  is  much  more  rapid,  and  the  ther- 
apeutic test  will  usually  lead  to  a  correct  diagnosis. 

The  syphilitic  ulcers  develop  quickly,  sometimes  in  a  few  days, 
and  are  surrounded  by  reddened,  oedematous  mucous  membrane. 
The  ulcers  are  usually  single,  and  involve  by  preference  the  upper 
surface  of  the  epiglottis.  Tubercular  lesions  require  months  for 
development. 

The  distinction  between  gummatous  and  carcinomatous  infiltra- 
tion is  dependent  on  somewhat  the  same  difference  in  symptoms, 
though  occasionally  microscopic  examination  of  an  excised  piece  will 
be  necessary  before  the  true  nature  of  the  case  can  be  determined. 
The  differential  diagnosis  between  syphilitic,  tuberculous,  and  cancer- 
ous laryngitis  may  be  tabulated  as  follows : 


Syphilis. 

Development  of  ulcer 
acute,  occupying  only 
a  few  days. 

Considerable  irregular  in- 
flammatory or  (Edema- 
tous swelling. 

Epiglottis  affected,  if  at 
all,  on  upper  surface. 

Ulcer  solitary  ;  rarely 
more  than  two. 

Proceeds  from  centre  to 
periphery,  or  from 
above  downward. 


Tubercle. 

Development  slow ;  fol- 
lows throat  symptoms 
after  several  months. 

Uniform,  pale  swelling, 
looking  like  an  infiltra- 
tion. 

Lower  surface. 

Ulcers  numerous. 

The  reverse  is  true. 


Cancer. 

Intermediate  in  time  ;  ap- 
pearance of  ulcers  in  a 
few  weeks. 

Nodular  excrescences  and 
acute  inflammation  of 
neighboring  mucous 
membrane. 

No  uniformity. 

Ulcer  solitary. 
Irregular  in  its  course. 


936  GEXITO-TJRI^^AKT    DISEASES   AND   SYPHILIS. 

Syphilis.  Tubercle.                                  Cancer. 

Deep,  round,  or  oval.  Generally  round.                      Irregular  in  shape. 

Diameter  of  one-third  to  Diameter  much    smaller      Diameter  much  smaller. 

one  inch.  (one-sixth      to       one- 
twelfth  inch). 

No  cachexia.  Phthisical  appearance.            Cachexia. 

Treatment  usually  highly  Treatment  has   but  very      Treatment  has  no  effect, 

beneficial.  moderate  effect. 

Prognosis. — The  prognosis  of  gummatous  laryngitis  is  extremely 
good  if  the  diagnosis  is  made  before  ulceration  has  had  time  to  effect 
much  destruction  of  tissue.  Resolution  under  specific  treatment  is 
usually  prompt.  When  ulceration  is  extensive,  medicine  cannot  pre- 
vent cicatricial  contraction  and  interference  with  function.  Under 
these  circumstances,  when  dyspnoea  sets  in,  dilatation  of  the  strictured 
portion,  often  supplemented  by  internal  laryngotomy  and  the  wearing 
of  an  intubation  tube,  or  tracheotomy,  will  be  necessary.  In  addition 
to  constitutional  treatment,  during  the  gummatous  stage  of  laryngitis 
the  lesion  should  be  touched  daily  with  iodine.  1  part,  potassium 
iodide,  10  parts,  glycerin,  100  parts  ;  it  having  been  previously  sprayed 
and  cleaned  by  antiseptic  solution  of  subhmate  1  to  2000.  Following 
this  the  lesion  should  be  dusted  with  iodol. 

Syphilis  of  the  Lungs. — The  trachea  and  bronchi  exhibit  the 
lesions  of  secondary  syphilis  in  the  form  of  mucous  patches,  which 
in  the  few  observed  cases  were  situated  on  the  posterior  walls  of 
these  tubes  and  were  credited  with  causing  an  obstinate  bronchitis, 
yielding  only  to  specific  treatment. 

Gummatous  ulceration  of  the  trachea  and  bronchi  may  be  exten- 
sive and  superficial,  or  localized  and  deep.  It  is  commonly  placed 
about  the  tracheal  bifurcation,  and  may  cause  necrosis  of  one  or  more 
rings,  these  in  some  few  cases  having  been  coughed  up.  As  a  result 
of  this  gummatous  ulceration  the  surrounding  organs  are  involved, 
and  in  some  cases  the  oesophagus,  the  aorta,  and  the  posterior  medi- 
astinum have  been  opened. 

If  the  respiratory  tubes  recover  from  the  inflammatory  proc- 
ess, subsequent  cicatricial  contraction  may  seriously  embarrass  respi- 
ration. 

Symjjtoms. — When  the  trachea  is  involved  there  may  be  an  obsti- 
nate cough,  with  expectoration  of  blood-stained  sputa,  and  some  pain 
and  tenderness  behind  the  sternum.  Large  tracheal  rales  may  be 
heard  on  auscultation.  When  the  bronchi  are  invaded  the  prognosis 
is  less  favorable  than  when  the  trachea  alone  is  attacked. 

Syphilis  may  attack  the  lungs  in  the  form  of  acute  catarrhal  or 
croupous  pneumonia,  somewhat  atypical  in  development,  symptoma- 


SYPHILIS   OF   THE   EESPIEATOEY   TKACT.  937 

tology,  and  course,  and  yielding  to  constitutional  treatment.     This  is 
exceptional. 

Lung-symptoms  depending  on  syphilis  usually  develop  in  the  late 
tertiary  period.     Two  forms  of  lesions  are  observed  : 

1.  Diffuse  sclerosis,  characterized  by  bronchial  catarrh,  and  alter- 
nate areas  of  dulness  and  resonance. 

2.  Circumscribed  syphilitic  gumma,  single  or  multiple,  usually 
found  in  the  middle  third  of  the  lungs,  but  occurring  also  at  the 
apices.  The  patient  may  exhibit  all  the  symptoms  of  typical 
phthisis. 

A  form  of  chronic  pneumonia  characterized  by  diffuse  interstitial 
infiltration  is  sometimes  characteristic  of  hereditary  syphihs.  This 
may  involve  the  entire  lung  or  only  a  portion  of  it,  and  is  a  frequent 
cause  of  death.  The  alveolar  septa  are  so  thickened  by  the  specific 
infiltrate  that  the  air-spaces  are  greatly  encroached  upon,  the  lungs 
cannot  expand,  and  the  pulmonary  circulation  is  interfered  with. 

Gummatous  pulmonitis,  the  so-called  syphilitic  phthisis,  under 
which  head  are  included  the  diffuse  and  circumscribed  infiltrations, 
develops  as  an  ordinary  case  of  consumption,  except  that  the  con- 
stitutional symptoms  are  at  first  less  marked  and  the  course  is  less 
rapid.  The  disease  begins  with  a  cough,  slight  dyspnoea,  and  mod- 
erate expectoration,  usually  without  fever.  Percussion  dulness  and 
bronchial  breathing  are  found  over  the  diseased  area.  As  the  gum- 
matous infiltrate  increases,  the  expectoration  becomes  more  profuse 
and  cavities  form.  Hectic  is  developed,  and  all  the  characteristic 
symptoms  of  advanced  phthisis  appear. 

The  mid-portions  of  the  lungs  are,  according  to  the  majority  of 
reports,  most  frequently  affected. 

Diagnosis. — The  diagnosis  is  founded  upon  a  syphilitic  history  and 
the  presence  of  other  manifestations  of  the  disease,  such  as  laryngeal 
lesions,  perforation  of  the  palate,  and  skin  cicatrices.  Tubercle  bacilli 
are  not  found  in  the  expectoration.  A  two  weeks'  treatment  by  in- 
unctions supplemented  by  iodide  internally  should  produce  marked 
improvement  of  symptoms  if  the  disease  is  syphilis.  Tuberculous 
involvement  is  made  worse  by  such  treatment. 

Primary  involvement  of  the  pleura,  with  characteristic  symptoms 
of  pleurisy,  is  almost  unknown.  There  may,  however,  be  a  pleuritis 
with  effusion  secondary  to  specific  pulmonary  involvement. 

Treatment. — This  is  practically  the  same  as  that  applicable  to  cases 
of  pulmonary  tuberculosis,  with  the  addition  of  potassium  iodide 
pushed  to  toleration,  supplemented  by  inunctious  of  mercury. 


CHAPTER   XXVI. 

SYPHILIS     OF    THE    BONES    AND    JOINTS. — OF    THE    MUSCLES. OF    THE    HEART 

AND     BLOOD-VESSELS. OF   THE    LYMPHATIC    SYSTEM. OF    THE    LIVER. 

OF   THE   SPLEEN. OF   THE   PANCREAS. OF  THE   GENITO-URINARY   ORGANS. 

Lesions  of  the  bones  are  among  the  most  frequent  manifestations 
of  constitutional  syphihs  ;  indeed,  as  a  seat  of  predilection,  the  osseous 
system  takes  second  rank,  being  surpassed  only  by  the  skin  and  mucous 
membrane. 

Symptoms  of  bone-involvement  may  appear  very  early,  at  times 
even  before  the  skin  eruptions.  Usually  the  lesions  are  distinctly 
tertiary  in  type  and  in  their  time  of  appearance. 

The  scrofulous  temperament,  cachexias  which  are  liable  to  be  at- 
tended with  alteration  of  the  bones,  as  gout  or  rheumatism,  and  par- 
ticularly traumatism,  often  slight  and  unnoticed  in  itself,  are  causes 
which  predispose  to  the  development  of  specific  bone-lesions.  Super- 
ficially placed  bones,  such  as  the  frontal  bone,  clavicle,  sternum,  radius, 
ulna,  and  tibia,  are  affected  most  frequently  mainly  because  they  are 
so  often  exposed  to  slight  injury. 

The  lesions  produced  by  syphilis  vary  from  a  simple  periostitis  to 
the  formation  of  typical  gummata.  These  lesions  may  undergo  resolu- 
tion, or  may  be  followed  by  exostosis,  eburnation,  caries,  and  necrosis. 
They  may  be  classed  under  the  following  heads  : 

1.  Simple  osteoperiostitis. 

2.  Rarefying  ostitis. 

3.  Gummatous  osteoperiostitis. 

Osteoperiostitis,  also  called  precocious  periostitis,  may  develop 
at  the  time  of  skin  eruption,  or  even  before  this,  within  three  weeks 
of  the  appearance  of  a  chancre ;  more  commonly  it  occurs  either 
in  the  first  three  months  of  the  disease  or  in  the  tertiary  period. 
Pathologically  it  does  not  differ  from  osteoperiostitis  due  to  non- 
specific causes.  The  periosteum  becomes  hyperaemic,  and  there  is 
cellular  infiltration  of  its  deeper  layers  and  the  contiguous  portion 
of  the  bone.  The  bones  of  the  cranium,  the  tibia,  the  ribs,  the  ster- 
num, and  the  clavicle  are  most  frequently  affected. 

Symptoms. — These  are  subacute  in  type.  On  examination  there  is 
detected  a  tender,  slightly  elastic  swelling,  evidently  growing  from 
the  bone ;  the  skin  may  be  slightly  puffed  and  reddened,  and  the 

938 


SYPHILIS   OF   THE   BONES   AND  JOINTS.  939 

•pain  is  often  intense,  especially  at  night.  Usually  the  symptoms  yield 
promptly  to  treatment,  the  swelling  disappearing  without  leaving  a 
trace  of  its  seat.  Sometimes,  however,  in  place  of  resolution,  osteo- 
genesis takes  place,  and  bony  nodules  called  osteophytes  permanently 
mark  the  seat  of  trouble  ;  or  from  a  deposit  of  bone  on  the  walls  of 
the  Haversian  canals  the  osseous  tissue  may  become  unduly  dense, 
resulting  in  eburnation. 

Rarefying  Ostitis. — When  the  inflammation  is  more  intense 
the  cellular  infiltrate  not  only  invades  the  lower  layer  of  the  perios- 
teum and  the  bone  surface,  but  penetrates  along  the  course  of  the 
Haversian  canals,  eroding  their  bony  walls,  and  substituting  for  the 
sohd  osseous  substance  soft  embryonal  tissue.  If  the  process  is  acute 
the  normal  tissue  may  entirely  disappear  at  the  seat  of  infiltration, 
and  suppuration  may  take  place,  resulting  in  the  formation  of  a  bone 
abscess  and  in  caries  or  necrosis. 

Usually  the  embryonal  tissue  gradually  encroaches  upon  the  bone- 
tissue,  till  the  latter  much  resembles  sponge  in  shape  and  structure, 
or  the  infiltrate  may  become  organized,  obliterating  the  lumen  of  the 
Haversian  canals,  and  filling  the  medullary  canal  with  a  hard,  heavy, 
compact,  osseous  tissue,  producing  eburnation.  Caries  and  necrosis 
may  also  occur  at  the  seat  of  eburnation  as  a  result  of  ischsemia  inci- 
dent to  obhteration  of  the  Haversian  canals. 

Gummatous  Periostitis,  Ostitis,  and  Osteomyelitis. — While 
the  simple  and  rarefying  forms  of  osteoperiostitis  offer  no  clinical  or 
pathological  features  which  will  distinguish  them  from  similar  lesions 
due  to  causes  other  than  syphihs,  the  formation  of  gummata  in  bone 
points  definitely  to  syphihs.  The  lesions  appear  as  tumors  varying 
in  size  and  exhibiting  a  tendency  towards  centric  caseous  degenera- 
tion. These  tumors  are  formed  by  rarefying  ostitis  in  which  the 
superabundant  subperiosteal  or  medullary  embryonal  tissue  under- 
goes the  changes  and  arrangement  characteristic  of  the  gumma. 
These  gummata  may  develop  in  the  deeper  layer  of  the  periosteum, 
in  the  bone-substance,  or  in  the  medullary  cavity.  They  are  usually 
multiple,  and  may  invade  any  portion  of  the  skeleton. 

The  gummatous  involvement  of  .the  bone  may  be  circumscribed 
or  diffuse. 

Circumscribed  gummatous  osteomyelitis  appears  in  long  bones  in 
the  form  of  nodules  developing  in  the  medullary  canal.  Centrally 
they  are  found  to  be  softened  or  undergoing  caseous  degeneration, 
while  peripherally  they  are  surrounded  by  a  sclerosed  area.  In  the 
spongy  tissue  the  gummata  are  imperfectly  encapsulated  by  the  same 
hbrous  formation. 


940 


GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 


Diffuse  Gummatous  Osteomyelitis. — The  lesions  of  this  form  of 
bone  syphilis  more  frequently  involve  the  soft  parts  in  gummatous 

changes,    resulting    in    the 
Fig.  310.  formation  of  fistulae  leading 

;"~:    -  _,  —  to  the  bone.     The  perios- 

teum is  always  infiltrated ; 
the  bone  is  greatly  deformed 
and  appears  worm-eaten. 
Its  surface  is  irregular, 
studded  with  osteophytes, 
perforated  with  small  or 
large  openings,  and  exceed- 
ingly unequal.  (Figs.  310, 
311.)  Some  of  these  per- 
forations are  small,  others 
as  large  as  two-fifths  of  an 
inch  in  diameter.  On  sec- 
tion of  the  bone  hyper- 
ostosis and  eburnation  will 
be  found  in  some  regions, 
and  marked  rarefaction  in 
others,  the  whole  bone 
being  considerably  in- 
creased in  volume.  The 
new  ossification  is  exceed- 
ingly irregular  in  position 
and  consistence.  The  bone 
is  often  so  brittle  that  the 
least  effort  is  enough  to 
break  it.  Indeed,  the  ir- 
regular eburnation  and  rarefaction  are  considered  by  Oilier  as  char- 
acteristic of  the  osseous  lesions  of  syphilis. 

All  these  lesions  are  marked  by  absence  of  suppuration  and  by 
the  rarity  of  extensive  necrosis.  As  a  result  of  intense  rarefying 
periostitis,  particularly  where  this  is  diffuse,  there  is  always  destruc- 
tion of  bone-tissue.  When  the  flat  bones  are  attacked,  lesions  may  be 
circular  or  semicircular  in  arrangement.  This  circinate  arrangement 
is  rarely  observed  iii  the  long  bones.  Nearly  always  associated  with 
the  destruction  of  tissue  there  is  noticed  peripherally  a  formative 
ostitis.  This  follows  the  course  of  destructive  action,  resulting  in 
overgrowth  and  eburnation. 

Necrosis  usually  results  in  consequence  of  the  too  energetic  osteo- 


SkuU  showing  the  results  of  gummatous  osteoperiostitis. 


SYPHILIS   OF   THE   BONES   AND  JOINTS. 


941 


genetic  action.  Most  of  the  sequestra  are  found  to  be  eburnated. 
Sometimes  the  bone  seems  almost  normal  in  structure,  often  being 
cut  off  from  its  nutrition  by  a  peripheral  gummatous  infiltration, 
which  obhterates  its  vessels  and  deprives  it  of  nutrition. 


Fig.  311. 


Vault  of  the  cranium  exhibiting  the  results  of  gummatous  osteoperiostitis. 

Tegumentary  lesions  may  cause  bone  necrosis  by  extension  of 
infiltration  to  the  periosteum  ;  thus  the  nasal  bones  and  cartilages  are 
most  frequently  destroyed. 

The  more  chronic  forms  resulting  in  osteosclerosis  and  osteoporo- 
sis are  attended  with  few  subjective  symptoms,  perhaps  nothing  more 
than  boring  nocturnal  pains,  which  are  usually  considered  as  rheu- 
matic. 

Symptoms. — The  symptoms  of  gummatous  bone-involvement  are, 
when  the  lesion  is  circumscribed  and  begins  in  the  periosteum,  fairly 
characteristic.  There  is  formed  a  painless,  sometimes  excessively 
painful,  non-inflammatory  tumor  of  slow  growth,  which  softens  cen- 
trally and  exhibits  a  peripheral  ring  of  dense  induration.  Several 
bones  are  often  invaded  at  the  same  time,  or  the  lesion  is  multiple, 
and  there  is  commonly  a  syphilitic  history  to  be  elicited.  The  diag- 
nosis between  syphilitic  and  tubercular  ostitis  will  be  founded  on  the 
points  of  difference  formulated  in  the  following  table  : 


942  GENITO-UEINAET  DISEASES  AND   SYPHILIS. 

Syphilitic  Ostitis.  Tubercular  Ostitis. 

Syphilitic    ostitis     occurs     in    varying  Ostitis  of  tuberculosis  occurs  in  persons 

physical  conditions.  who   have   other  symptoms   of   this 

disease. 

Begins  most   frequently  in  the  perios-  Begins  in  the  medulla. 

teum. 

Tends  to  the  formation  of  new  bone  or  Tends  to  disintegration  of  the  parts. 

necrosis. 

Is   often   unaccompanied   by    suppura-  Generally  terminates  in  the  formation 

tion.  of  pus. 

Does  not  involve  neighboring  articula-  Apt  to  do  so. 

tions. 

Frequent  in  bones  of  the  cranium.  Scarcely  ever  found  in  this  situation. 

Histologically,   consists  of  a  relatively  Made  up  of  a  varying  number  of  tubercle 

large  mass  of  granulation-tissue.  granulations  and  surrounded  by  iso- 
lated granules. 

In  the  majority  of  cases  can  be  cured,  or  Nothing  short  of  operative  interference 

at  least  arrested,  if  taken  in  time,  by  materially  affects  the  course  of  this 

judicious  specific  treatment.  disease. 

Osteosyphilosis  of  the  Cranium. — Precocious  osteoperiostitis 
and  ostitis,  together  with  tertiary  exostoses,  are  frequently  observed 
in  the  bones  of  the  cranium.  The  exostoses  may  develop  upon  both 
the  external  and  the  internal  table.  In  the  latter  case  they  are  danger- 
ous to  life  from  pressure  and  from  the  meningitis  which  they  excite. 
Rarefying  ostitis  and  gummatous  periostitis  are  often-  observed,  with 
consecutive  eburnation,  as  are  also  circumscribed  gummata.  These 
lesions  may  develop  in  the  diploe,  or  in  the  pericranium,  or  in  the 
dura,  involving  the  bone  subsequently. 

When  placed  upon  the  cranium  the  gummatous  lesions  exhibit  a 
circinate  arrangement  and  cause  but  scanty  suppuration.  Frequently 
small  and  multiple  gummata  will  involve  a  considerable  extent  of  sur- 
face, circumscribing  a  large  portion  of  the  internal  or  the  external 
table,  which  eburnates,  becomes  ischsemic,  and  necroses.  When  the 
pericranium  alone  is  involved,  the  external  table  is  destroyed.  When 
the  syphiloma  is  located  in  the  dura  mater,  it  is  the  internal  table 
alone  that  is  involved.  When  syphilomata  of  the  pericranium  and 
the  dura  are  developed  on  opposite  portions  of  the  same  bone,  com- 
plete perforation  may  result.  This  may  also  follow  from  a  gumma 
developing  in  the  diploe. 

Gummata  of  the  dura  mater  are  accompanied  by  a  circumscribed 
pachymeningitis,  which  is  sometimes  hemorrhagic.  Frequently  these 
gummata  developing  upon  the  dura  are  followed  by  no  external  signs, 
though  sometimes  they  may  consecutively  involve  the  soft  tissues  and 
suppurate.     Dry  caries  resulting  in  the  formation  of  stellar  cicatrices, 


SYPHILIS   OF   THE   BONES   AND   JOINTS.  943 

sometimes  in  complete  perforation,  due  to  gummatous  infiltration 
followed  by  absorption,  is  comparatively  rare.  Usually  the  soft  parts 
are  involved,  and  there  is  the  ordinary  form  of  caries  or  necrosis. 

The  external  exostoses  of  the  cranial  bones  are  similar  to  those 
observed  in  the  other  parts  of  the  body.  Exostoses  encroaching  upon 
the  brain  are  interesting  from  the  fact  that  they  sometimes  occasion 
compression  symptoms  and  excite  meningitis  or  encephalitis. 

These  projections  are  noticed  over  the  frontal,  parietal,  temporal, 
and  occipital  bones. 

Some  instances  of  general  hyperostosis  due  to  syphilis  have  been 
observed. 

The  bones  of  the  face,  particularly  those  of  the  nose,  are  favorite 
seats  of  gummatous  infiltration.  The  affection  may  develop  primarily 
in  the  bone,  or  may  be  secondary  to  ulcerating  or  tubercular  gumma 
of  the  soft  parts.  The  superior  maxilla  frequently  exhibits  these 
lesions,  particularly  the  alveolus,  the  palatal  plate,  and  the  nasal 
process.     The  disease  usually  goes  on  to  necrosis. 

The  vertebrae  exhibit  the  ordinary  bone-lesions  of  syphilis,  but 
are  perhaps  especially  apt  to  suffer  from  circumscribed  gummata. 
Caries  and  necrosis  may  develop,  followed  by  spinal  deformity, — 
syphilitic  Pott's  disease.  As  in  tubercular  disease  of  the  spine,  the 
cord  and  its  envelopes,  the  spinal  nerves,  and  the  surrounding  parts 
may  be  affected  either  by  pressure  of  the  infiltrate  or  by  involvement 
in  the  inflammatory  process. 

Osteosyphilosis  of  the  foramina  may  from  the  swelling  cause  pain, 
analgesia,  or  paralysis,  due  to  pressure  upon  the  spinal  nerves. 

The  tibia  is  more  often  involved  in  tertiary  syphilis  than  any  other 
of  the  long  bones.  Caries,  necrosis,  and  exostoses  are  frequently 
noted. 

The  Phalanges. — Syphilitic  dactylitis  appears  in  the  form  of  a 
gummatous  deposit,  which  may  involve  the  subcutaneous  connective 
tissue  of  the  fingers  and  toes,  together  with  the  periosteum  and  bones 
of  these  parts.  This  involvement  appears  in  a  superficial  and  in  a 
deep  form. 

In  the  superficial  form  there  is  gummatous  infiltration  of  the  sub- 
cutaneous tissues,  which  subsecfuently  involves  the  ligaments  sur- 
rounding the  joints.  If  the  toes  are  affected  they  generally  exhibit 
the  lesions  through  their  entire  length.  In  the  fingers  the  hardening 
and  enlargement  are  commonly  limited  to  a  single  phalanx. 

Syphilitic  dactylitis  is  characterized  by  a  slow,  painless  swelling, 
most  marked  on  the  dorsal  aspect  of  the  finger,  and  rarely  extending 
farther  up  than  the  metacarpo-phalangeal  articulation.    There  is  some 


944  GEXITO-UEIXAEY   DISEASES   AND    SYPHILIS. 

discoloration  of  the  affected  area ;  the  region  of  the  joint  becomes 
swollen,  and  from  softening  of  its  ligaments  there  results  preter- 
natural mobility.  These  enlargements  exhibit  an  ultimate  tendency 
towards  softening  and  ulceration.     Hydrarthrosis  is  rarely  observed. 

This  form  of  the  disease  develops  as  a  late  secondary  or  distinctly 
tertiary  manifestation. 

The  deep  form  appears  as  a  specific  osteomyelitis  and  periostitis. 
It  usually  involves  an  entire  carpus  or  tarsus,  though  it  may  be  con- 
fined to  the  opposing  extremities  of  two  phalanges.  The  proximal 
phalanges  of  the  fingers  are  commonly  attacked,  often  several  at  one 
time.  When  the  metacarpal  bones  are  also  involved,  these  are  gen- 
erally of  the  thumb  and  the  index  finger. 

This  form  occurs  late  in  the  disease,  from  five  to  fifteen  years 
after  the  appearance  of  chancre.  It  is  chiefly  limited  to  the  bones 
and  the  periosteum,  the  integument  being  seldom  involved.  Some- 
tmies,  however,  when  the  process  is  rapid  and  extensive,  ulceration, 
caries,  and  necrosis  result.  As  the  joint  becomes  involved,  the  carti- 
lages are  eroded  and  crepitus  may  be  detected.  From  infiltration  of 
the  ligaments  and  capsule  the  function  of  the  joint  may  be  seriously 
interfered  with,  the  latter  being  sometimes  rendered  too  loose,  or, 
again,  from  extensive  swelling  motion  being  almost  entirely  pre- 
vented. Even  when  ulceration  does  not  take  place  there  may  be 
shortening  or  deformity  of  the  bone  consequent  upon  dry  caries  or 
interstitial  absorption. 

S^^philitic  dactylitis   occurs  much  more   frequently  in  hereditary 

than  in  acquired  s}Tohilis.     The  fingers  are  less  frequently  affected 

than  the  toes. 

SYPHILIS   OF   THE   JOIXTS. 

Arthralgia. — During  the  secondary  period  arthralgia  is  a  common 
and  early  manifestation  of  constitutional  disease.  This  sometimes 
precedes  the  eruption,  and  may  be  unaccompanied  by  fever.  Pain, 
which  is  often  much  worse  at  night,  is  the  only  sjmiptom.  There  are 
no  discoverable  lesions. 

Synovitis  may  develop  at  the  same  time  ;  usually  it  comes  later; 
it  may  be  either  polyarticular  or  monarticular,  or  may  appear  in  the 
form  of  hydrarthrosis. 

Acute  polyarticular  synovitis  is  characterized  by  practically  the 
same  pathological  changes  that  are  observed,  for  instance,  in  poly- 
articular rheumatism. 

Reference  to  the  symptomatology  and  diagnosis  of  this  affection 
has  already  been  made.  In  one  or  two  weeks,  especially  if  specific 
treatment  is  instituted,  resolution  takes  place. 


SYPHILIS   OF   THE   BONES  AND  JOINTS.  945 

Acute  monarticular  synovitis  exhibits  the  same  symptoms  as  the 
polyarticular  form  of  the  affection,  except  that  the  disease  is  strictly 
confined  to  one  joint,  usually  the  knee,  is  intensified,  and  is  much 
more  hable  to  become  chronic.  Moreover,  it  yields  slowly  to  treat- 
ment. This  monarticular  form  of  trouble  sometimes  follows  the  poly- 
articular involvement,  resolution  taking  place  in  all  but  a  single  joint. 
Pathological  changes  are  in  this  case  more  pronounced. 

Hydrarthrosis,  or  chronic  hypertrophic  synovitis,  pursues  prac- 
tically the  same  course  as  chronic  synovitis  from  other  causes.  There 
is  thickening.  The  synovial  membrane  is  tufted,  and  there  is  a  gum- 
matous infiltration  extending  even  to  the  articular  cartilages  and  the 
ligaments.  There  is  a  marked  effusion  into  the  joint,  and  ultimately 
it  may  be  rendered  useless,  either  from  limitation  of  motion  or  from 
absolute  fixation.  When  there  is  extensive  involvement  of  the  car- 
tilages and  bones,  osteophytes  may  form,  resulting  in  partial  or 
complete  bony  ankylosis. 

Gummatous  arthritis,  a  late  manifestation  of  syphilis,  is  char- 
acterized by  the  development  of  gumma,  primarily  of  the  ligaments  or 
articular  cartilages,  generally  accompanied  by  the  synovial  changes 
encountered  in  hydrops  articuh, — i.e.,  thickening  and  tufting  of  the 
synovia.  In  certain  cases  the  nodular  gummatous  infiltration  may 
be  distinctly  felt  in  the  general  swelling  involving  the  joint. 

The  amount  of  serous  effusion  varies  greatly.  Either  resolution 
may  take  place  or  the  joint-cavity  may  open  and  suppurate.  The 
joints  may  be  secondarily  involved  from  gummatous  or  ulcerative 
processes  of  the  overlying  parts,  or  of  the  bones  entering  into  their 
formation. 

The  joints  most  frequently  involved  are  the  sterno-clavicular  and 
the  knee ;  the  elbow,  the  wrist,  and  the  ankle  follow  next  in  order  of 
frequency. 

Symptoms. — Gummatous  synovitis  when  it  develops  first  in  the 
capsular  synovia  causes  few  symptoms  aside  from  an  apparently 
movable,  circumscribed  tumor.  Exceptionally  the  whole  joint  be- 
comes cj[uickly  swollen,  and  there  are  limitation  of  motion  and  rapid 
muscular  atrophy.  Ultimately  there  are  more  or  less  fixation  and  per- 
manent deformity.  If  the  bone  is  involved  in  the  gummatous  process 
the  swelling  is  usually  more  marked,  the  articular  extremity  of  the  in- 
volved bone  becoming  distinctly  thickened,  and  muscular  atrophy  is  ex- 
tremely rapid.  The  subjective  symptoms  are  often  in  their  mildness 
out  of  proportion  to  the  apparent  severity  of  the  lesions.  With  a  greatly 
swollen  and  inflamed  knee-joint  the  patient  may  be  able  to  walk  with 
comparative  ease  and  comfort.     If,  however,  the  cartilage  has  been 

60 


946  GENITO-URINAKT   DISEASES   AND   SYPHILIS. 

eroded  there  may  be  total  disability,  and  in  any  event  there  is  likely 
to  be  more  or  less  pain,  particularly  severe  at  night. 

Diagnosis. — The  comparative  rarity  of  syphilitic  joint  affections 
and  their  similarity  to  tuberculous  involvement  often  lead  to  an  in- 
correct diagnosis  and  to  the  needless  loss  or  sacrifice  of  an  articula- 
tion. This  is  particularly  true  of  the  knee-joint.  Syphilitic  synovitis 
presents  no  chnical  feature  in  its  course  by  which  it  can  be  distin- 
guished from  other  forms  of  synovitis.  The  tuberculin  and  thera- 
peutic tests  should  be  employed  in  all  doubtful  cases.  In  the  acute 
forms  of  the  affection  the  absence  of  heart-lesions  and  failure  of  anti- 
rheumatic remedies  may  suggest  the  true  nature  of  the  synovitis. 

Chronic  syphilitic  hydrarthrosis,  in  the  absence  of  a  historj^  of 
other  signs  or  symptoms  of  syphilis,  cannot  be  distinguished  from 
tubercular  synovitis  except  by  the  tuberculin  and  therapeutic  tests. 
Under  the  use  of  mercury  and  potassium  iodide  enormous  effusions 
may  slowly  disappear. 

Gummatous  arthritis  and  synovitis  can  be  positively  diagnosed  only 
by  the  evidence  offered  by  other  lesions  of  syphilis,  such  as  ulcerating 
gummata  of  the  skin.  Tubercular  arthritis  differs  from  the  gumma- 
tous in  the  fact  that  it  is  often,  though  not  necessarily,  associated  with 
characteristic  tuberculous  lesions  elsewhere,  that  it  is  more  prone  to ' 
ulcerate  and  open  externally,  and  that  it  produces  more  rapid  and 
extensive  destruction  of  the  bone. 

Prognosis. — The  prognosis  of  syphilitic  joint  disease  is  compara- 
tively good  when  the  affection  develops  early  in  the  course  of  syphilis 
and  is  recognized  and  promptly  treated.  Later,  atrophic  changes,  or 
those  due  to  infection,  produce  permanent  deformity  and  disability. 
The  synovitis  yields  readily  to  specific  treatment.  Arthritis,  even 
though  cartilages  and  joints  are  extensively  involved  and  there  are 
contraction  and  deformity,  is  also  curable  by  constitutional  treatment, 
reinforced  in  .cases  characterized  by  abscess  formation  and  bone 
necrosis  by  sequestrectomy,  partial  arthrectomy,  or  other  surgical 
procedure.  Even  when  total  arthrectomy  is  required,  provided  the 
nature  of  the  disease  has  been  recognized,  the  prognosis  is  infinitely  better 
than  if  the  joint  disease  has  been  due  to  causes  other  than  syphilis. 

Treatment. — The  treatment  of  syphilitic  joints  consists  in  the  ad- 
ministration of  mercury  and  potassium  iodide,  except  in  the  forms 
occurring  in  the  beginning  of  the  secondary  period,  when  mercury 
alone  should  be  given.  The  local  treatment  is  the  same  as  that 
appropriate  to  other  forms  of  non-suppurative  arthritis.  Rest  and 
pressure  procured  by  splints  and  bandages,  counter-irritation,  and 
in  later  stages  massage  are  mdicated. 


SYPHILIS   OF   THE   MUSCLES.  947 

Bursitis. — The  bursee  may  become  acutely  inflamed,  exhibiting 
the  characteristic  symptoms  of  this  affection.  This  is  extremely 
rare. 

Much  more  common,  though  still  rarely  encountered,  is  gumma- 
tous bursitis,  usually  observed  in  the  prepatellar  bursa,  appearing  in 
the  form  of  a  nodular,  painless,  fluctuating  swelling,  which  is  prone 
to  soften  and  break  down. 

SYPHILIS   OF  THE   MUSCLES. 

Acute  irritative  myositis  develops  very  exceptionally  during 
the  first  year  of  secondary  syphilis.  The  symptoms  are  identical 
with  those  of  a  muscular  rheumatism  which  is  slow  in  onset  and 
somewhat  chronic  in  type. 

There  is  dull  pain,  aggravated  by  pressure  or  motion.  Sometimes 
this  is  exceedingly  severe.  The  biceps  and  triceps  are  most  fre- 
quently involved.  They  sometimes  exhibit  irritative  contraction  se- 
riously interfering  with  the  motion  of  the  part  and  controlled  only 
by  constitutional  treatment. 

The  symptoms  yield  readily  to  vigorous  mercurial  treatment. 

Tertiary  syphilis  may  attack  the  muscles  in  the  form  of — 

1.  Chronic  interstitial  myositis. 

2.  Gummatous  myositis. 

Chronic  interstitial  myositis  begins  as  a  cellular  infiltration  of 
the  muscular  fibres ;  the  infiltrate  subsequently  becomes  organized 
into  connective  tissue,  resulting  in  muscular  contractures  and  atrophy. 

The  pathological  changes  are  most  marked  in  the  bellies  of  the 
muscles ;  the  anal  sphincter  and  the  humeral  biceps  are  most  fre- 
quently involved,  though  contractions  of  the  sterno-cleido-mastoid, 
pectoraKs  major,  rectus  abdominahs,  masseter,  and  many  other 
muscles  have  been  noted. 

Symptoms. — There  are,  in  addition  to  severe  pain,  slight  tender- 
ness, Mmitation  of  motion,  and  diffuse  swelhng.  As  the  disease  pro- 
gresses the  muscle  atrophies  and  shortens. 

Diagnosis. — Chronic  syphilitic  myositis  when  unaccompanied  by 
other  and  more  characteristic  signs  of  syphilis  may  imitate  muscular 
rheumatism.  The  syphilitic  affection  is,  however,  unattended  by 
constitutional  symptoms  or  joint-involvement.  It  develops  without 
apparent  cause.  It  is  slowly  and  persistently  progressive,  and  is 
shortly  accompanied  by  contracture.  Moreover,  it  exhibits  marked 
predilection  for  certain  muscles.  In  all  these  points  it  differs  from 
muscular  rheumatism.  The  therapeutic  test  should  positively  decide 
the  matter. 


948  GENITO-UEINAKY  DISEASES   AND  SYPHILIS. 

Gmnmatous  myositis  differs  from  the  interstitial  infiltration 
only  in  the  facts  that  it  is  circumscribed,  forms  a  distinct  tumor,  often 
involves  neighboring  parts,  and  exhibits  a  tendency  to  degenerate, 
soften,  and  discharge. 

Gummata  of  muscle  are  usually  late  manifestations  of  syphihs ; 
in  the  malignant  forms  of  the  disease  these  may  develop  in  the  first 
year,  and  under  such  circumstances  are  apt  to  suppurate. 

Symptoms. — Usually  gummata  develop  as  painless,  slowly  growing 
tumors,  seated  at  the  point  of  insertion  of  the  muscle  or  in  its  belly, 
movable  with  the  latter,  but  fixed  when  it  is  strongly  contracted ;  ex- 
ceptionally, when  infiltration  is  rapid,  there  may  be  great  pain  and 
tenderness.  The  tumor  usually  reaches  the  size  of  a  man's  fist. 
Sometimes  it  grows  to  the  size  of  a  child's  head ;  it  may  then  simu- 
late malignant  disease  so  closely  that  the  therapeutic  test  alone  will 
enable  a  diagnosis  to  be  made.  These  gummata  are  absorbed, 
soften,  or  become  converted  into  dense  fibroid  masses.  The  trape- 
zius, pectoralis  major,  gluteus,  biceps,  and  lingual  muscles  are  oftenest 
affected. 

Prognosis. — Diffuse  interstitial  myositis  and  muscular  gummata  if 
treated  early  yield  completely  to  iodides  and  mercury ;  later,  when 
the  muscular  fibres  have  atrophied  and  cicatricial  contractions  have 
occurred,  constitutional  treatment  is  unavailing,  except  to  prevent  fur- 
ther extension  of  the  syphilitic  process. 

Syphilitic  tenosynovitis  may  appear  in  the  acute,  the  chronic, 
or  the  gummatous  form. 

Acute  Tenosynovitis  may  develop  in  the  early  secondary  period, 
and  is  characterized  by  effusion,  tenderness,  and  swelling  along  the 
course  of  the  tendon.  It  subsides  quickly  under  specific  treatment. 
Several  tendons  may  be  affected  simultaneously,  and  there  may  be 
great  pain  and  tenderness,  and  an  associated  syphilitic  synovitis  with 
fever.     The  affection  is  more  common  in  women  than  in  men. 

Chronic  Tenosynovitis. — Rarely,  chronic  tenosynovitis  develops, 
characterized  by  effusion  and  crepitation  along  the  course  of  the  ten- 
don. It  is  accompanied  by  some  thickening  of  the  sheath,  especially 
observed  about  the  extensor  tendons  of  the  fingers  and  toes  and  the 
biceps  tendon. 

Chronic  syphilitic  tenosynovitis  is  usually  painless  and  yields  slowly 
to  constitutional  treatment.  It  presents  the  same  symptoms  as  the 
non-specific  inflammations  of  the  tendon-sheaths. 

Gummatous  Tenosynovitis. — Gummata  sometimes  develop  in  the 
sheath  of  the  tendon.  These  are  painless,  and  are  either  round  or 
spindle-shaped.     Exceptionally  the  gumma  appears  in  the  form  of  a 


SYPHILIS   OF  THE   CIKCULATOKY   SYSTEM.  949 

diffuse  infiltration.  These  gummata  subside  promptly  under  specific 
treatment.  They  are  most  frequently  found  on  the  tendo  Achillis 
and  the  biceps  tendon.  The  diagnosis  is  usually  facilitated  by  the 
presence  of  gummata  elsewhere,  particularly  in  the  muscles.  In  tlie 
absence  of  these  or  other  signs  of  syphilis,  a  trial  of  specific  treatment 
should  be  instituted.  The  development  of  the  gumma  usually  distin- 
guishes it  from  other  tumors,  enchondroma,  for  instance,  since  sooner 
or  later,  in  the  absence  of  specific  treatment,  the  gumma  softens  and 
breaks  down,  forming  a  characteristic  ulcer. 

SYPHILIS   OF   THE   CIRCULATORY   SYSTEM. 

Heart. — Syphilitic  involvement  of  the  heart  is  exceedingly  rare. 
It  usually  appears  as  a  late  tertiary  manifestation,  according  to  Jullien, 
about  the  tenth  year  after  the  infecting  chancre,  though  it  may  de- 
velop in  the  first  year  of  constitutional  syphilis.  The  disease  appears 
as  a  diffuse  chronic  myocarditis  or  in  the  form  of  gummata. 

Syphilitic  Myocarditis. — Fusiform  areas  of  small  round-celled  in- 
filtration of  the  heart-muscle  first  appear ;  these  become  converted 
into  connective  tissue  and  form  thick,  white  cicatrices.  The  cica- 
trices are  usually  few  in  number,  and  are  found  in  the  walls  of  the 
left  ventricle,  frequently  lying  just  below  the  endocardium  or  peri- 
cardium. 

Gummatous  myocarditis  develops  in  the  form  of  tumors,  varying 
from  the  size  of  a  pea  to  that  of  a  pigeon's  egg.  These  tumors  present 
the  same  appearance  as  gummata  in  other  regions ;  that  is,  there  is  a 
central  caseous  mass,  surrounded  by  a  thick,  fibrous  sheath,  in  the 
periphery  of  which  the  muscular  fibres  are  in  a  condition  of  fatty 
degeneration. 

Endocarditis  and  Pericarditis. — Syphilitic  inflammation  of  the 
membranes  of  the  heart  is  rarely  primary.  It  is  commonly  found 
about  the  regions  where  gummata  or  patches  of  chronic  myocarditis 
have  developed.  When  the  endocardium  of  the  valves  is  attacked, 
insufficiency  may  result  from  cicatricial  contraction. 

Symptoms. — The  symptoms  of  syphilitic  involvement  of  the  heart 
or  its  envelopes  are  exceedingly  vague.  Generally  the  affection  is  not 
detected  until  it  is  so  far  advanced  that  treatment  offers  little  prospect 
of  cure.  Sometimes  patients  complain  of  shortness  of  breath,  palpita- 
tion, anginose  pains,  or  irregularity  of  the  pulse.  At  the  same  time 
examination  of  the  heart  shows  an  increased  area  of  dulness,  some 
muffling  of  the  sounds,  and  frequently  blowing  murmurs,  the  exact 
cause  and  location  of  which  it  is  difficult  to  discover. 


950  GENITO-UKINAEY  DISEASES  AND  SYPHILIS. 

In  all  these  symptoms  there  is  nothing  characteristic.  The  diag- 
nosis can  be  made  only  by  exclusion  and  by  eliciting  a  history  of 
preceding  syphilis. 

Prognosis. — This  must  always  be  guarded.  The  disease  passes 
through  its  various  phases  so  slowly  and  with  so  few  symptoms  that 
it  is  rarely  suspected  until  cicatrices  have  formed.  In  a  large  number 
of  the  reported  cases  death  has  been  sudden  and  unexpected.  In 
three  cases  death  occurred  during  defecation. 

Treatment. — The  treatment  consists  in  the  administration  of  potas- 
sium iodide,  the  doses  being  rapidly  pushed  to  the  extreme  limit  of 
toleration.  At  the  same  time  remedies  appropriate  to  the  functional 
troubles,  as  evidenced  by  the  chnical  symptoms,  should  be  given. 

Arteries. — Syphilitic  involvement  of  the  arteries  is  generally  a 
tertiary  lesion,  but  has  been  observed  in  the  first  few  months  of  the 
constitutional  disease. 

Syphilitic  arteintis  may  be  acute  or  chronic  in  type.  In  either  case 
the  pathology  is  much  the  same.  There  is  at  first  a  cellular  infiltra- 
tion, usually  beginning  as  a  periarteritis  and  involving  all  the  coats  of 
the  vessel,  causing  its  walls  to  become  irregularly  thick,  hard,  and 
non-elastic,  and  narrowing  or  quite  obliterating  the  blood-channel. 
Even  should  the  infiltration  not  mechanically  close  the  vessel  lumen, 
as  a  result  of  endarteritis,  thrombi  frequently  form,  thus  preventing 
circulation  through  the  diseased  area. 

Endarteritis  may  be  of  the  sclerous  or  of  the  gummatous  type.    * 

Sclerous  endarteritis  is  the  commonest  form  of  the  affection. 
The  infiltrate  is  converted  into  fibrous  tissue,  producing  whitish, 
opaque  patches  of  hardening,  which  may  appear  as  disseminated 
plaques  or  as  small  nodulations,  usually  involving  the  entire  circum- 
ference of  the  vessel. 

Gummatous  endarteritis  is  extremely  rare ;  it  is  always  associated 
with  the  sclerous  degeneration  and  with  periarteritis,  and  on  section 
shows  the  broken-down,  cheesy  contents  of  the  typical  gumma. 

Syphilitic  arteritis  affects  usually  the  smaller  arteries,  and  particu- 
larly those  of  the  brain.  By  weakening  the  vessel-walls  and  by  in- 
creasing the  blood-pressure  from  local  obstruction  to  circulation  the 
disease  strongly  predisposes  to  the  formation  of  aneurism. 

Symptor)is. — The  symptoms  of  syphilitic  arteritis  depend  upon  the 
disturbances  of  function  incident  to  the  ischserhia  which  follows  nar- 
rowing or  obliteration  of  the  arterial  lumen.  When  collateral  circula- 
tion is  readily  established,  but  little  functional  disturbance  may  result 
from  obstruction  of  one  or  more  vessels.  When  there  is  no  provision 
for  collateral  circulation,  however,  as  in  the  areas  supplied  by  smaller 


SYPHILIS  OF   THE   LYMPHATIC  SYSTEM.  951 

cerebral  arteries, — and  it  is  these  that  are  most  frequently  implicated 
in  syphilitic  arteritis, — functional  disturbances  may  be  pronounced. 

Cerebral  ischsemia  from  syphilitic  arteritis  is  characterized  by 
frontal  headache,  followed  in  weeks  or  months  by  epileptiform  at- 
tacks, hebetude,  somnolence,  hemiplegia,  particularly  marked  in  the 
upper  extremity,  usually  attacking  the  right  side,  accompanied  by 
aphasia,  and  sometimes  coming  on  without  loss  of  consciousness,  and 
finally  by  coma  and  death. 

When  in  consequence  of  syphilitic  arteritis  aneurism  develops,  be- 
yond a  history  of  syphilis  and  the  presence  of  other  manifestations  of 
the  disease  there  are  no  diagnostic  signs  which  would  point  to  the 
nature  of  the  lesion.  These  aneurisms  form  mostly  in  the  brain,  and 
produce  much  the  same  functional  disturbances  as  have  been  described 
as  attendant  on  sclerous  arteritis. 

Occasionally  the  larger  vessels  are  involved.  Cases  of  aortic 
aneurism  almost  certainly  originating  in  syphilitic  changes  in  the  walls 
of  the  great  vessels  have  been  reported. 

Prognosis. — The  prognosis  of  syphilitic  arteritis  is  bad.  This  is 
because  symptoms  rarely  develop  till  sclerosis  is  well  advanced,  and 
particularly  in  the  case  of  the  brain,  because  the  alterations  in  the 
nerve-structure  are  often  irremediable.  Aneurisms  occasionally  yield 
to  constitutional  treatment,  and  angina  may  promptly  disappear  after 
a  course  of  potassium  iodide  and  mercury,  never  to  recur. 

Veins. — The  veins  rarely  exhibit  syphilitic  lesions.  Mauriac  in- 
stances a  single  case  of  phlebitis  and  thrombosis  involving  several 
vessels  and  occurring  in  the  first  few  months  of  constitutional  syphilis. 

Phlebitis  in  secondary  syphilis  is  characterized  by  superficial  local- 
ization, multiplicity  of  veins  involved,  absence  of  embolism  or  serious 
complications,  and  recovery  under  specific  treatment. 

SYPHILIS   OF  THE   LYMPHATIC   SYSTEM. 

While  primary  and  secondary  syphilis  produce  almost  invariably 
marked  effects  upon  the  lymphatic  glands,  the  tertiary  form  of  the  dis- 
ease manifests  itself  in  the  lymphatic  system  with  comparative  rarity. 

The  surface  glands  are  much  more  rarely  involved  than  are  those  in 
the  neighborhood  of  viscera.  Of  the  deep  glands,  post-mortem  exami- 
nations have  shown  that  those  ordinarily  involved  are  the  bronchial, 
the  pulmonary,  the  mediastinal,  the  hepatic,  and  the  gastric. 

The  superficial  glands  most  frequently  affected  are  those  in  the 
supraclavicular,  intraclavicular,  cervical,  inguinal,  and  axillary  re- 
gions. Patients  of  a  scrofulous  temperament  are  most  subject  to 
these  enlargements. 


952  GENITO-TJEINAKY  DISEASES   AND  SYPHILIS. 

The  sclerous  and  gummatous  types  are  recognized.  Both  are 
characterized  by  primary  enlargement  incident  to  hypertrophy  and 
cell  proliferation.  The  tumor  formed  is  at  first  regular  in  outline, 
smooth,  freely  movable  beneath  the  skin,  and  indurated. 

Enlargement  of  a  single  gland  is  rare.  Usually  a  whole  group  of 
glands  in  one  region  of  the  body  is  involved.  The  tumors  vary  from 
the  size  of  a  cherry  to  that  of  a  man's  fist.  Usually  they  are  no 
larger  than  a  hickory-nut.  Having  reached  this  stage,  the  tumors 
may  slowly  undergo  resolution,  taking  sometimes  months  or  even 
years  to  accomplish  this ;  or  exceptionally  they  may  continue  to  en- 
large, becoming  soft,  adhering  to  the  skin,  and  ulcerating,  discharging 
thick,  yellowish  pus  containing  shreds  of  necrotic  tissue.  The  small 
opening  at  first  formed  becomes  rapidly  large,  with  indurated,  ragged 
edges  surrounded  by  a  brownish-red  area  of  congestion. 

Exuberant  granulations  may  be  formed,  resulting  in  fungoid 
growths. 

Specific  treatment  and  local  applications  cause  rapid  heahng  of 
these  ulcers.  There  remains  a  deep,  irregular,  pigmented  scar.  Oc- 
casionally these  ulcerating  syphilitic  lymphomata  become  phagedenic, 
exposing  the  patient  to  the  dangers  incident  to  this  form  of  inflam- 
mation. 

Diagnosis. — The  diagnosis  of  syphilitic  lymphomata  is  often  ex- 
ceedingly difficult,  and  can  be  established  only  by  careful  attention  to 
the  history  of  the  case. 

Syphilitic  adenopathy  may  closely  simulate  tubercular  adenitis. 
The  latter,  however,  is  usually  observed  in  infants,  or  at  least  during 
early  adult  life ;  is  accompanied  by  other  evidences  of  a  tubercular 
diathesis  ;  attacks  by  preference  the  cervical  and  submaxillary  glands ; 
is  more  generalized,  and  forms  larger  tumors  ;  commonly  exhibits  sup- 
purative periadenitis  with  formation  of  fistulous  tracts  not  distinctly 
ulcerative  in  type  ;  does  not  become  phagedenic,  and  is  not  improved 
by  specific  treatment.  Cancerous  adenopathy  is  nearly  always  sec- 
ondary. The  tumor  grows  rapidly,  becomes  adherent  to  surround- 
ing tissues,  ulcerates,  bleeds,  and  progresses  in  spite  of  treatment, 
producing  profound  cachexia. 

Prognosis. — Except  in  cases  where  general  ulcerating  lymphomata 
become  phagedenic,  the  prognosis  is  exceedingly  good. 

Treatment. — Early  treatment  nearly  always  occasions  prompt  reso- 
lution. Both  potassium  iodide  and  mercury  should  be  given,  the  for- 
mer drug  in  full  doses,  the  latter  internally,  and  locally  in  the  form 
of  inunctions.  Even  when  distinct  fluctuation  is  noted,  the  knife 
may  not  be  necessary. 


SYPHILIS   OF   THE    LIVER.  953 

Local  counter-irritation  and  the  administration  of  tonic  and  sup- 
porting treatment  will  hasten  resolution. 

Ulcerating  gummata  of  the  lymphatic  glands  are  exceedingly  rare. 
The  treatment  is  that  of  other  tertiary  lesions. 

SYPHILIS   OF   THE   LIVER. 

The  liver  may  be  affected  in  both  the  secondary  and  the  tertiary 
period  of  syphilis.  Involvement  in  the  secondary  period  is  exceed- 
ingly rare ;  tertiary  lesions,  however,  affect  the  liver  more  frequently 
than  they  do  any  other  abdominal  organ. 

Precocious  syphilis  of  the  hver  appears  in  the  first  three 
months  of  the  constitutional  disease  as  hypertrophy,  which  may  or 
may  not  be  accompanied  by  pain,  tenderness,  and  jaundice.  The 
hypertrophy  is  general,  and  may  enlarge  the  liver  to  twice  its  normal 
size.  On  palpation  no  nodules  are  found,  simply  a  general  increase 
in  size.  The  prognosis  is  good,  the  enlargement  gradually  diminish- 
ing under  constitutional  treatment,  till  in  from  one  to  three  months 
the  liver  is  again  normal  in  size. 

Jaundice  developing  during  the  secondary  period  is  rarely  due  to 
syphilis.  The  great  majority  of  such  cases,  when  unattended  by 
hepatic  enlargement,  are  caused  by  intercurrent  affections,  such  as  a 
catarrhal  condition  of  the  bile-ducts,  and  are  neither  directly  nor 
indirectly  dependent  upon  constitutional  syphilis.  Calvert  has,  how- 
ever, collected  one  hundred  and  twenty-seven  cases  of  jaundice  occur- 
ring as  a  manifestation  of  secondary  syphihs,  and  notes  that  it  is  rapid 
in  appearance,  varies  greatly  in  intensity,  recurs,  and  is  not  associated 
with  grave  digestive  disturbances.  Icterus  gravis  is  most  exceptional. 
The  diagnosis  is  based  on  the  history  and  associated  symptoms  of 
syphilis  and  upon  the  rapid  improvement  under  specific  treatment. 

Tertiary  syphilis  of  the  liver  may  appear  as  interstitial  hepa- 
titis or  as  gummatous  hepatitis.  These  tertiary  lesions  are  in  marked 
contrast  to  the  secondary  involvement  of  the  liver  from  the  fact  that 
they  rarely  appear  till  late  in  the  disease,  from  the  fourth  to  the  fortieth 
year.  They  are  frequent,  they  are  persistent  and  rebellious  to  treat- 
ment, and  they  produce  permanent  alteration  in  the  liver-substance. 

The  abuse  of  alcohol,  traumatism,  and  carelessness  in  treatment 
seem  to  be  the  factors  which  particularly  predispose  the  liver  to  ter- 
tiary manifestations  of  syphilis. 

Interstitial  Hepatitis  (diffuse  gummatous  infiltration). — This  runs 
very  much  the  course  of  an  ordinary  cirrhosis.  It  begins  as  a  hyper- 
aemia,  accompanied  by  an  abundant  small  round-celled  infiltration 
of  the  perivascular  connective  tissue  of  the  liver.    This  .cellular  hyper^ 


954  GENITO-URINAEY    DISEASES   AND   SYPHILIS. 

plasia  generally  appears  in  disseminated  patches  of  perihepatitis,  result- 
ing in  adhesions  to  surrounding  organs.  The  infiltration  of  the  sub- 
stance of  the  liver  may  be  general,  though  it  is  commonly  found  in 
patches.  The  cellular  infiltrate  becomes,  in  part  at  least,  converted  into 
connective  tissue,  vvrhich  by  its  contraction  causes  narrowing  and  ob- 
literation of  ducts  and  vessels  and  atrophy  of  liver-cells.  There  is  at 
first  an  increase  in  the  size  of  the  liver,  general  or  localized,  depend- 
ing upon  wliether  hyperaemia  and  cellular  infiltrates  are  diffuse  or 
appear  in  discrete  patches.  Ultimately,  as  the  round-celled  infiltrate 
in  part  undergoes  fatty  degeneration  and  is  absorbed,  in  part  becomes 
converted  into  connective  tissue  and  contracts,  the  enlarged  liver  be- 
comes smaller;  but  this  lessening  in  size  does  not  stop  when  the 
organ  has  reached  its  normal  dimensions  ;  the  atrophic  process  steadily 
advances ;  the  surface  of  the  organ  is  lobulated,  is  marked  by  deep 
furrows,  is  creased  by  dense  fibrous  bands,  and  the  liver  is  distorted 
almost  beyond  recognition.  The  contraction  of  the  fibrous  bands  is 
often  so  pronounced  that  some  of  the  lobulations  thus  produced  are 
almost  completely  cut  off  from  the  rest  of  the  liver,  seeming  to  be 
attached  only  by  the  fibrous  tissue  surrounding  the  base. 

Together  with  atrophy  in  one  portion  of  the  liver  there  may  be 
overgrowth  in  another.  This  may  be  due  to  amyloid  degeneration  or 
to  compensatory  hypertrophy,  the  intact  portion  of  the  liver-substance 
developing  so  that  it  may  take  the  place  of  the  portion  destroyed. 

The  furrowing  and  lobulation  are  usually  much  more  distinctly 
marked  upon  the  convex  than  upon  the  concave  surface  of  the  organ. 

Gummatous  hepatitis  is  characterized  by  the  formation  of  gummata 
identical  in  structure  with  similar  tumors  observed  in  other  portions 
of  the  body.  These  tumors  vary  from  the  size  of  a  pea  to  that  of  a 
hen's  egg;  they  are  most  frequently  found  in  the  region  of  the  sus- 
pensory ligament  and  along  the  course  of  the  portal  vein,  though  they 
may  appear  in  any  part  of  the  liver ;  they  may  be  grouped  or  irregu- 
larly disseminated.  They  are  gray  or  yellowish  in  color,  and  either 
solid  throughout  or  broken  down  in  the  centre,  according  to  the 
period  of  evolution. 

As  the  gummata  soften  centrally,  undergoing  fatty  and  caseous 
degeneration  arid  becoming  absorbed,  the  peripheral  portion  of  the 
neoplasm  is  converted  into  fibrous  tissue,  which  contracting  produces 
on  the  surface  of  the  liver  deep  irregular  puckerings,  sometimes  so 
marked  as  seemingly  to  divide  the  right  lobe  of  the  liver  into  two 
halves.  In  the  deeper  portion  of  the  liver  irregular  branching  nodules 
are  formed,  in  the  centre  of  which  is  sometimes  found  a  small  amount 
of  caseous  material. 


SYPHILIS   OF   THE   LIVEK.  955 

There  is  nearly  always  associated  with  these  gumma  a  perihepatitis, 
resulting  in  adhesions  between  the  liver  and  surrounding  structures ; 
this  is  particularly  marked  on  the  upper  surface,  and  may  so  limit  the 
respiratory  movements  of  the  organ  as  to  constitute  a  sign  of  some 
diagnostic  value.  Interstitial  hepatitis  and  amyloid  degeneration  of 
the  liver,  spleen,  kidneys,  and  intestinal  mucous  membrane  are  also 
frequently  noted  in  connection  with  old  gummata. 

The  gummata  of  the  liver  do  not  ulcerate ;  they  develop  slowly, 
and  may  not  reach  their  ultimate  stage  of  cicatrization  for  several  years. 

Symptoms. — The  symptoms  of  syphilitic  interstitial  hepatitis  are 
rarely  well  marked.  In  the  early  stage  there  is  a  feeling  of  weight  in 
the  hepatic  region,  followed,  often  after  a  long  period,  by  hypertrophy, 
slow  in  development,  and  unattended  by  signs  of  inflammation.  Some- 
times the  hypertrophy  is  general,  the  lower  border  of  the  liver  ex- 
tending three  flnger-breadths  below  the  margin  of  the  ribs,  and  re- 
vealing to  palpation  a  smooth,  regular  surface.  Often  the  hypertrophy 
is  not  so  marked,  palpation  showing  surface  irregularities  or  eleva- 
tions. It  is  dependent  upon  compression  of  the  portal  vein  from  peri- 
vascular hyperplasia. 

Functional  disturbances  are  limited  to  general  dyspeptic  symp- 
toms, even  these  not  being  noted  at  times.  As  the  disease  progresses 
and  atrophy  sets  in,  the  only  sign  which  may  be  considered  charac- 
teristic is  the  deformity  incident  to  cicatricial  contraction.  A  nodu- 
lar surface,  an  irregular  fissured  border,  gradually  becoming  less  per- 
ceptible to  palpation  in  one  portion  while  overgrowth  is  observed  in 
another  region,  and  adhesions  to  surrounding  structures,  are  all  signs 
which  would  suggest  syphilis. 

Icterus  is  comparatively  rare ;  hsematemesis,  diarrhcEa,  digestive 
troubles,  and  swelhng  of  the  legs  develop  as  in  the  case  of  cirrhosis 
from  causes  other  than  syphihs. 

Ascites  is  frequently  noted ;  fluid  accumulates  slowly  in  the  first 
place,  but  on  tapping;  reaccumulates  rapidly.  Often  there  are  no  pre- 
monitory symptoms  ;  a  painless  ascites  gradually  develops,  associated 
with  jaundice,  discolored  urine,  swelhng  of  the  ankles,  varicose  veins, 
and  possibly  albuminuria. 

Gummatous  hepatitis  in  the  early  stages  may  give  rise  to  no  symp- 
toms, and  may  not  seriously  interfere  with  the  functions  of  the  hver. 
As  the  disease  progresses,  the  accompanying  hepatitis,  perihepatitis, 
and  amyloid  degeneration  cause  most  of  the  suffering  and  interference 
with  general  health.  The  liver  is  usually  of  normal  size,  presenting 
to  the  examining  finger  a  nodular  irregular  border.  Gastro-intestinal 
symptoms  are  marked,  pain  may  be  severe  and  constant,  and,  v/hen 


956  GENITO-UKINAEY    DISEASES   AND   SYPHILIS. 

the  atrophic  process  is  well  developed,  bleeding  from  the  stomach  or 
from  the  oesophagus  may  become  a  serious  complication. 

Enlargement  of  the  spleen  and  albuminuria  are  commonly  asso- 
ciated with  specific  hepatitis.  As  a  consequence  of  this  involvement 
of  the  liver,  spleen,  and  kidneys,  pronounced  cachexia  ensues. 

Prognosis. — The  prognosis  of  tertiary  syphihs  of  the  liver  is,  if  the 
affection  is  taken  in  its  earher  stages,  fairly  good.  The  gummatous 
form  yields  more  readily  to  specific  treatment  than  the  diffuse  or  cir- 
rhotic form.  When  extensive  fibroid  changes  have  taken  place,  and 
particularly  when  there  are  associated  lesions  of  the  kidneys  and  spleen 
and  marked  cachexia,  the  prognosis  must  be  exceedingly  guarded. 

Diagnosis. — The  diagnosis  of  liver  syphilis  is  founded  upon  altera- 
tions in  the  size  and  shape  of  the  liver,  associate'd  with  much  milder 
symptoms  than  are  attendant  on  such  alterations  when  they  are  due 
to  other  causes.  There  is  usually  a  history  of  syphilis ;  digestive 
troubles  are  not  very  pronounced,  or,  if  marked,  do  not  develop  till 
late  in  the  disease  ;  serous  effusion  into  the  peritoneal  cavity  is  mod- 
erate in  quantity,  but  is  quickly  reproduced  after  having  been  evacu- 
ated. These  features  will  aid  in  distinguishing  the  ordinary  cirrhotic 
liver  from  that  affected  by  syphilitic  diffuse  interstitial  hepatitis. 

Gummatous  hepatitis  may  simulate  cancer.  The  latter  affection, 
however,  occurs  in  those  past  middle  age,  involves  both  lobes  of  the 
liver,  and  is  rarely  primary.  It  is  not  so  liable  to  contract  adhesions 
as  are  gummata :  hence  its  nodulations  are  more  readily  felt ;  it  is  ac- 
companied by  pain  and  jaundice,  and  produces  early  and  profound 
cachexia ;  it  grows  much  more  rapidly  than  gumma,  and  associated 
enlargement  of  the  spleen  is  rare. 

Treatment. — All  forms  of  hepatic  syphilis  occurring  in  the  early 
secondary  period  should  be  treated  by  mercury. 

In  the  form  generally  observed — that  is,  as  a  late  tertiary  mani- 
festation— potassium  iodide  should  be  administered  in  large  doses, 
beginning  with  thirty  grains  a  day  and  running  the  dose  up  by  five 
grains  a  day  till  the  symptoms  yield  or  iodism  is  produced.  The  dose 
required  is  sometimes  as  high  as  two  or  three  drachms  daily. 

In  addition  to  the  potassium  iodide,  mercurial  inunctions  should 
be  given  at  intervals.  Tonics,  mild  stimulation,  bathing,  exercise, 
diet,  and  general  hygiene  must  receive  careful  consideration. 

Amyloid  degeneration  is  so  frequently  associated  with  syphilis  that 
the  latter  must  be  recognized  as  an  etiological  factor  in  its  production. 
As  when  it  compMcates  tuberculosis,  it  may  follow  extensive  sup- 
purative processes.  It  is  also  found,  however,  in  conjunction  with  the 
sclerotic  or  the  gummatous  form  of  hepatitis,  and  is  commonly  com- 


SYPHILIS   OF   THE    SPLEEN.  957 

plicated  by  a  similar  affection  of  the  spleen,  the  kidneys,  and  often  the 
intestinal  mucous  membrane.  The  liver  rarely  reaches  the  enormous 
size  sometimes  observed  in  amyloid  degeneration  from  other  causes. 

In  itself  amyloid  degeneratioa  does  not  cause  ascites,  and  gives 
rise  to  no  functional  disturbances  until  it  is  far  advanced.  Ultimately 
digestive  disturbances  become  pronounced,  and,  as  the  result  of  sim- 
ilar degeneration  of  the  intestinal  mucosa,  multiple  ulcers  develop, 
causing  blood-stained  stools.  There  is  usually  oedema,  and,  if  the 
kidneys  are  also  involved,  albuminuria.     Cachexia  is  well  marked. 

The  diagnosis  is  based  on  finding  an  enlarged,  smooth,  firm,  non- 
sensitive  liver,  together  with  other  signs  of  late  syphilis.  In  amyloid 
degeneration  with  gummatous  or  sclerotic  processes  the  liver  may 
be  ridged,  notched,  or  otherwise  deformed. 

The  prognosis  is  extremely  grave.  The  treatment  is  that  appro- 
priate to  late  syphilis,  combined  with  tonics,  stimulants,  carefully 
regulated  diet,  and  minute  attention  to  general  hygiene. 

SYPHILIS   OF   THE   SPLEEN. 

The  spleen,  closely  associated  as  it  is  with  the  lymphatic  system 
of  the  body,  is  frequently  affected  in  secondary  syphilis.  There  is  a 
distinct  enlargement,  usually  occurring  early,  but  sometimes  not  for 
several  months.  This  enlargement  is  not  followed  by  functional 
troubles.  There  is  nothing  to  call  the  patient's  attention  to  the 
swelling,  and  it  is  rarely  observed  unless  careful  search  is  made  for 
it.  It  commonly  subsides  in  the  course  of  a  few  weeks  or  months. 
The  pathology  is  probably  the  same  as  that  of  the  lymphatic  glandular 
enlargement  of  secondary  syphilis. 

Tertiary  syphilis  may  produce  gummata  or  disseminated  or  local- 
ized splenitis,  resulting  ultimately  in  partial  cirrhosis.  These  lesions 
rarely  betray  themselves  in  life  by  appreciable  symptoms.  It  is  only 
as  the  result  of  post-mortem  examination  that  their  existence  has 
been  proved. 

They  may  be  suspected  when  physical  examination  shows  increase  in 
the  volume  and  consistence  of  the  spleen  and  when  deep  pressure  elicits 
tenderness.  They  are  nearly  always  associated  with  similar  lesions  of 
the  liver  and  kidneys,  the  symptoms  of  which  completely  mask  splenitis. 

Pronounced  leucocytosis  and  the  finding  of  pigmented  masses  in 
the  blood  may  suggest  involvement  of  the  spleen. 

SYPHILIS   OF   THE    PANCREAS. 
Specific  disease  of  this  organ  may  take  the  form  of  interstitial 
pancreatitis  or  of  gummatous  involvement. 


958  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

These  lesions  are  exceedingly  rare.  Their  presence  is  not  indi- 
cated by  characteristic  symptoms  during  life.  There  is  usually  marked 
involvement  of  other  abdominal  organs. 

SYPHILIS   OF  THE   URO-GENITAL   SYSTEM. 

The  Kidneys. — The  kidneys  are  less  frequently  involved  in  the 
lesions  of  syphilis  than  are  the  genitals,  the  nervous  system,  or  the 
liver.  They  may  be  attacked  at  any  time  during  the  course  of  the 
constitutional  disease,  the  lesions  produced,  with  the  exception  of 
gummata,  being  identical  with  those  which  characterize  Bright's 
disease  in  all  its  varieties. 

As  etiological  factors,  tuberculosis,  rheumatism,  gout,  and  alco' 
holism  are  all  of  some  importance,  but  the  direct  exciting  cause  is 
either  the  syphilitic  virus  or  the  irritating  toxins  produced  by  it  in 
the  body  and  probably  excreted  through  the  kidney  epithehum. 

Precocious  involvement  of  the  kidney  often  closely  follows  the 
chancre,  and  is  manifested  by  albuminuria,  usually  intermittent, 
transitory,  and  moderate.  The  total  quantity  of  urine  passed  daily  is 
not  diminished,  nor  is  the  specific  gravity  markedly  affected.  Micro- 
scopic examination  at  most  may  show  a  few  hyahne  casts.  This 
albuminuria  develops  during  the  early  eruptive  period  and  subsides 
promptly  under  treatment. 

Acute  syphilitic  parenchymatous  nephritis  is  characterized  by 
lesions  of  the  glandular  part  of  the  organ,  producing  a  condition 
analogous  to  that  termed  large  white  kidney.  It  is  in  reality  a  paren- 
chymatous nephritis,  and  differs  in  no  way  from  this  acute  or  sub- 
acute form  of  Bright's  disease,  presenting  the  same  complications  and 
sometimes  terminating  fatally. 

Albuminuria,  granular  epithehal  and  blood  casts,  lessened  secretion 
of  urine,  headache,  oedema,  and  other  symptoms  and  signs  of  acute 
nephritis,  are  present. 

The  diagnosis  is  founded  on  examination  of  the  urine,  the  acute 
rapid  course  of  the  affection,  the  associated  symptoms  of  syphilis,  and 
the  therapeutic  test. 

The  prognosis  is  favorable.  If  parenchymatous  nephritis  develops 
in  late  syphilis  and  is  associated  with  gummatous  infiltration  or  amyloid 
degeneration  of  other  viscera,  the  chances  of  cure  are  slight. 

Specific  treatment  is,  however,  usually  curative,  although  the  albu- 
minuria sometimes  persists  and  the  nephritis  becomes  chronic. 

The  more  profound  kidney  degenerations  characteristic  of  tertiary 
syphilis,  but  sometimes  occurring  in  the  late  secondary  period,  are 
syphilitic  interstitial  nephritis  and  gummatous  nephritis. 


SfPHILIS   OF   THE   UEO-GENITAL   SYSTEM.  959 

Syphilitic  interstital  nephritis  presents  the  same  pathology  and 
lesions  as  the  non-specific  form  of  the  disease.  The  symptoms  are 
those  of  chronic  Bright's  disease.  This  affection  is  more  grave  than 
the  early  nephropathy.  Indeed,  after  fibrous  tissue  has  once  fairly 
developed,  complete  restoration  of  the  kidney  to  its  normal  condition 
is  impossible. 

There  is  first  a  cellular  infiltration  of  the  interstitial  stroma  and 
of  the  walls  of  the  vessels  and  perivascular  spaces.  This  infiltration 
is  followed  by  sclerosis,  causing  atrophy  and  distortion  of  the  kidney, 
particularly  noticeable  in  the  cortex. 

The  symptoms  of  specific  interstitial  nephritis  are  the  same  as 
those  of  the  non-syphilitic  affection.  There  are  polyuria,  lowered 
specific  gravity,  light  straw  color  of  the  urine,  moderate  amount  of  albu- 
men, hyaline  and  granular  casts,  increased  arterial  tension,  oedema, 
headache,  asthma, — indeed,  all  the  well-known  symptoms  of  chronic 
nephritis. 

The  diagnosis  as  to  the  specific  nature  of  the  affection  can  be 
made  only  by  finding  other  signs  or  symptoms  of  syphihs. 

The  prognosis  is  unfavorable. 

Gummatous  nephritis  is  rare.  The  individual  tumors  rarely  reach 
large  size.  Cornil  states  that  they  are  usually  multiple  and  are  found 
chiefly  in  the  cortical  substance  or  in  the  pyramids.  Interstitial 
nephritis  is  nearly  always  found  in  conjunction  with  them. 

Jaccoud  states  that  amyloid  degeneration  is  by  far  the  most  com- 
mon manifestation  of  renal  syphilis.  Next  in  order  of  frequency 
comes  granular  atrophy ;  third,  gumma. 

Wagner  describes  a  fourth  form,  which  he  calls  syphilitic  glo- 
merulo-nephritis.  It  is  characterized  chiefly  by  hsematuria  and  ends 
rapidly  in  uraemia. 

There  have  been  a  number  of  carefully  studied  cases  of  diabetes 
insipidus  of  syphilitic  origin :  at  least  the  prompt  yielding  of  symp- 
toms to  specific  treatment  suggested  the  syphilitic  nature  of  the 
affection. 

The  treatment  of  the  tertiary  kidney-lesions  is  conducted  on  the 
same  general  principles  as  would  apply  to  cases  of  chronic  Bright's 
disease.  Mercury  must  be  administered  cautiously,  since  on  account 
of  the  crippled  condition  of  the  kidneys  it  is  extremely  hable  to  pro- 
duce toxic  symptoms.  Potassium  iodide  is  the  drug  upon  which  main 
rehance  should  be  placed.     It  must  be  given  in  full  doses. 

Amyloid  degeneration  of  the  kidney  is  associated  with  one  or  more 
of  the  forms  of  syphilitic  nephritis.  Similar  degenerations  of  other 
organs,  notably  the  liver  and  the  spleen,  are  present,  and  occasion 


960 


GENITO-URINAKY   DISEASES  A:ND  SYPHILIS. 


profound  cachexia.  There  are  no  characteristic  symptoms.  The 
prognosis  is  bad. 

The  Ureters  and  the  Bladder, — Syphilitic  involvement  of  the 
ureters  and  the  bladder,  so  far  as  symptoms  are  concerned,  is  prac- 
tically unknown.  Some  few  cases  of  ulceration  of  the  bladder  have 
been  described.      (See  page  436.) 

The  Epididymis  and  Testicles. — The  syphilitic  virus  may 
manifest  its  influence  upon  these  organs  either  in  the  form  of  inter- 
stitial inflammation  characterized  by  infiltration,  formation  of  connective 
tissue,  and  atrophy,  or  in  that  of  gummata. 

As  clinically  observed,  syphilitic  lesion  of  the  testicle  appears  as  a 
combination  of  the  forms  just  mentioned.  Both  epididymis  and  tes- 
ticle may  be  involved,  the  sclerous  and  gummatous  processes  going 
hand  in  hand.  There  is  often  an  accompanying  hydrocele.  The 
lesions  may  be  observed  at  almost  any  period  of  syphilis  from  the 
second  month  to  the  twentieth  year. 

Syphilitic  Epididymitis. — The  epididymis  when  involved  com- 
monly presents  an  indolent,  non-inflammatory,  indurated,  sharply 
circumscribed  gumma,  usually  of  the  right  globus  major.  Both  epi- 
didymes  may  be  affected  simultaneously. 

Involvement  of  the  epididymis  without  implication  of  the  testicle  is 
rare.  It  usually  develops  towards  the  end  of  the  secondary  period  of 
the  disease.  It  may  be  observed  at  any  time  during  the  secondary 
eruptions,  and-  at  this  period  undergoes  prompt  resolution  on  treat- 
ment, since,  like  all  the  secondary  lesions,  it  has  no  marked  tendency 
towards  sclerosis  or  caseous  degeneration. 

When  it  develops  in  the  late  tertiary  period  it  corresponds  more 
closely  to  the  type  of  the  tertiary  lesions, — that  is,  it  tends  to  break 
down  and  ulcerate.  This  occurrence  is  much  rarer,  however,  than  is 
the  case  with  tubercular  lesions. 

The  enlargement  never  attains  great  size.  There  are  rarely  more 
than  two  nodules,  which  after  some  months  become  of  almost  car- 
tilaginous hardness.  Exceptionally  there  may  be  a  number  of  small 
nodules,  grouped  at  either  extremity  of  the  epididymis,  the  middle 
portion  being  spared. 

Sometimes  this  affection  may  be  acute  in  its  onset  and  accom- 
panied by  inflammatory  symptoms.  On  examination,  however,  a 
rounded  tumor  at  the  head  of  the  epididymis,  or  at  both  the  head 
and  the  tail,  with  slightly  irregular  surface,  not  adherent  to  the  sur- 
rounding tissues,  probably  circumscribed,  and  without  fusion  into  the 
tunica  vaginalis,  suggests  the  nature  of  the  lesion. 

Diagnosis. — The  diagnosis  of  syphiloma  of  the  epididymis  i,s  read- 


SYPHILIS  OF   THE   URO-GENITAL   SYSTEM.  961 

ily  made.  The  absence  of  pain,  of  tenderness,  of  involvement  of  the 
skin,  and  of  hydrocele,  together  with  the  infiltration  of  the  head  of 
the  epididymis  rather  than  of  the  tail,  would  exclude  gonorrhoeal 
epididymitis. 

From  tubercular  epididymitis  a  differential  diagnosis  based  upon 
the  local  symptoms  alone  may  be  difficult.  The  tubercular  infiltrate 
usually  involves  the  caput  major,  producing  a  hard,  painless  indura- 
tion much  like  that  characteristic  of  syphilis.  This  steadily  grows 
larger,  presents  a  more  irregular  and  nodulated  surface  than  does  the 
syphiloma,  becomes  adherent  to  the  skin  of  the  scrotum,  softens,  and 
discharges,  forming  fistulse.  Tubercle  bacilli  can  be  demonstrated  in 
the  discharge  by  inoculation.  The  cord  becomes  indurated,  and  the 
seminal  vesicles  and  prostate  are  usually  involved 

Treatment. — Mixed  treatment  is  indicated. 

Syphilitic  Orchitis. — After  the  skin  and  subcutaneous  tissues 
and  the  bones,  the  testicle  is  the  most  frequent  seat  of  tertiary  syphi- 
lis. This  organ  may  be  involved  in  the  early  months  of  the  secondary 
period  ;  usually  the  third  year  is  the  time  during  which  tertiary  symp- 
toms develop. 

The  affection  may  assume  the  sclerous  or  gummatous  form,  though 
it  must  always  be  recognized  that  these  two  processes  run  their  courses 
side  by  side,  and  that,  while  the  predominant  lesion  may  appear  as  a 
cellular  infiltration  of  the  albuginea  and  its  trabeculse  followed  by 
cicatricial  contraction,  an  examination  of  the  diseased  testicle  shows 
the  presence  of  small  or  large  gummata.  Per  contra.,  even  though  the 
affection  appears  to  be  entirely  gummatous,  it  is  always  associated 
with  a  greater  or  less  degree  of  interstitial  orchitis.  Whether  the 
lesion  conforms  to  the  sclerous  or  to  the  gummatous  type,  its  onset  is 
insidious,  and  it  is  often  bilateral.  Its  course  is  exceedingly  chronic, 
and  it  terminates  in  (1)  resolution,  (2)  partial  or  complete  atrophy, 
or  (3)  destruction  by  ulceration. 

The  most  important  predisposing  cause  of  syphilitic  sarcocele  is 
gonorrhoeal  epididymitis ;  traumatism  or  sexual  excesses  may  also 
lessen  local  resistance. 

Interstitial  or  sclerous  orchitis  is  the  common  form  of  syphilitic 
sarcocele.  It  may  be  unilateral  or  bilateral.  Beyond  a  sense  of 
weight  and  enlargement,  its  onset  is  characterized  by  no  subjective 
symptoms. 

The  testicle  enlarges  uniformly  to  two  or  three  times  its  normal 
bulk.  It  forms  an  indurated,  non-sensitive  tumor.  The  epididymis 
is  flattened  along  its  posterior  border,  so  that  it  becomes  dilficult  to 
recognize  it  on  palpation.     The  cord  is  rarely  involved.     The  surface 

61 


962  GENITO-URIFAEY  DISEASES   AND   SYPHILIS. 

of  the  tumor  is  usually  smooth,  though  it  may  be  nodular  or  ridged. 
Testicular  sensation  on  pressure  is  lost. 

The  tumor  forms  slowly,  requiring  weeks  or  months  for  its  com- 
plete evolution.  It  may  remain  stationary  for  months,  and  finally 
subside,  leaving  an  apparently  normal  testicle,  or,  in  place  of  reso- 
lution, there  may  be  sclerogenesis  and  complete  atrophy,  the  testicle 
disappearing  and  the  vas  terminating  in  a  fibrous  nodule. 

It  is  to  be  noted  that  even  though  both  testicles  are  involved 
there  is  not  necessarily  either  impotence  or  sterility,  since  the  infil- 
tration generally  spares  some  of  the  secreting  portion  of  the  gland. 

Acute  Syphilitic  Orchitis. — Exceptionally  this  sclerous  orchitis 
may  depart  from  its  ordinary  type  and  the  symptoms  may  become  so 
acute  as  entirely  to  obscure  the  diagnosis.  In  this  form  of  the  dis- 
ease the  testicle  rapidly  swells,  and  becomes  exceedingly  sensitive ; 
the  scrotum  is  reddened  and  oedematous,  and  there  is  violent  and 
constant  pain. 

Commonly  but  one  testicle  is  affected.  Acute  symptoms  last  but  a 
few  days.  The  inflammation  comes  on  without  exciting  cause,  rarely 
presents  symptoms  as  acute  as  those  of  an  inflammatory  orchitis,  and 
is  distinguished  from  gonorrhcEal  epididymitis  by  the  fact  that  the  tes- 
ticle is  primarily  enlarged  and  presents  the  same  form  and  density  as 
are  observed  in  the  ordinary  syphilitic  sarcocele. 

As  a  rule,  the  tunica  vaginalis  is  not  affected  in  syphilitic  sarcocele, 
or  there  is  but  moderate  serous  effusion.  This  is  sometimes  circum- 
scribed, and  may  assume  a  pseudo-membranous  form.  Exceptionally 
the  effusion  is  so  great  as  to  prevent  palpation  of  the  testicle. 

Gummatous  Orchitis. — The  development  of  gummata  is  often  pre- 
ceded by  the  sclerous  type  of  syphilis  of  the  testicle,  though  fre- 
quently the  affection  is  distinctly  gummatous  from  its  onset.  In  place 
of  the  general  enlargement,  or  rather  accompanying  this,  distinct 
nodules,  ridges,  or  tumors  appear,  usually  on  the  anterior  surface  of 
the  testicle.  These  tumors  increase  in  size.  The  tunica  vaginalis 
becomes  adherent ;  the  overlying  skin  of  the  scrotum  is  infiltrated 
and  reddened,  and  finally  softening  and  ulceration  take  place,  with 
evacuation  of  broken-down  granulation-tissue  and  gummy  pus.  The 
resulting  punched -out  hollow  ulcer  has  dusky  indurated  borders,  and 
communicates  with  a  ragged,  irregular  cavity  containing  gray  un- 
healthy granulations.  The  scar  left  after  healing  is  adherent  to  the 
testicle. 

At  times  the  granulation-tissue  slightly  proliferates,  and  forms  a 
cauliflower  growth  projecting  externally  and  overlapping  the  seat  of 
skin  perforation  ;  this  is  known  as  a  benign  syphilitic  fungus. 


SYPHILIS   OF   THE   UEO-GENITAL   SYSTEM. 


963 


There  are  two  varieties  of  syphilitic  fungus, — the  superficial  and 
the  deep.  Both  originate  from  ulcerating  gummata.  The  superficial 
fungus  starts  from  gumma  of  the  scrotal  tissues  or  of  the  tunica  albu- 
ginea.  A  superficial  form  which  is  almost  identical  and  is  more  com- 
mon is  due  to  tubercle. 

Parenchymatous  or  deep  fungus  is  usually  syphilitic.  It  arises 
from  gumma  of  the  testicle  proper.  The  granulations  grow  upward 
through  the  albuginea  and  the  tissues  of  the  scrotum.  At  times  por- 
tions of  the  seminiferous  tubules  will  be  found  in  the  discharge. 

Softening  and  ulceration  do  not  always  take  place.  As  in  the  case 
of  interstitial  orchitis,  gumma  may  spontaneously,  or  from  the  effect 
of  treatment,  undergo  resolution,  leaving  the  testicle  apparently  as 
healthy  as  before  the  attack,  or  crippled  and  deformed  by  cicatricial 
contraction. 

Diagnosis. — The  diagnosis  of  sarcocele  in  its  typical  form  is  not 
difficult.  This  affection  commonly  develops  when  other  unmistakable 
manifestations  of  syphilis  are  present.  The  tubercle  bacillus  and  the 
gonococcus  when  they  invade  the  testicle  attack  the  epididymis  pri- 
marily ;  tubercle  commonly  invades  the  cord,  the  seminal  vesicles, 
and  the  prostate.     Syphihs,  however,  hardly  ever  attacks  the  cord. 

Finally,  the  effect  of  constitutional  treatment  will  be  found  a  valu- 
able means  of  clearing  the  diagnosis. 

The  differential  diagnosis  between  syphilitic  sarcocele  and  that 
due  to  carcinoma  or  tubercle  may  be  tabulated  as  follows : 


Syphilitic  Orchitis. 
Syphilitic  history. 

Usually  occurs  at  about 
twenty-five  or  thirty 
years  of  age. 

Begins  in  the  testicle. 

Is  situated  primarily  in 
the  connective  tissue. 

Tends  to  fibrous  over- 
growth. 


Slow  in  its  progress. 
Skin  of  the  scrotum  rarely 
involved. 


Encephaloid  Carcinoma 

of  Testicle. 

No  history  of  any  special 

condition. 
Occurs  at  any  age. 


Begins  in  the  body  of  the 
organ. 

Begins  by  the  deposit  of 
small  nodules  in  the 
seminiferous  tubules. 

Tends  to  formation  of 
patches  of  softened, 
white,  pultaceous  ma- 
terial. 

Rapid  in  its  course. 

Skin  of  the  scrotum  finally 
involved. 


Tubercular  Orchitis. 
Tubercular  history. 

Not  often  seen  after  thirty. 


Begins  in  the  epididymis. 

Exists    primarily   in    the 
tubules. 

Tends  to  fatty,  caseous,  or 
purulent  degeneration. 


Slow  in  its  progress. 
Skin   involved    only  just 

before  the  formation  of 

abscess. 


964 


GENITO-UKINAKY  DISEASES   AND  SYPHILIS. 


Syphilitic  Orchitis. 

Ulceration  or  suppuration 
rare. 

Fistulse  rare. 

A  feeling  of  great  weight, 
with  only  such  pain  as 
results  from  dragging 
on  the  cord. 

Tumor  very  hard  and  uni- 
form. 

Skin  of  scrotum  purplish, 
but  unaffected. 

Testicle  of  moderate  size  ; 
rarely  exceeds  twice  its 
normal  diameter. 

Painless  on  pressure. 

Both  testicles  often  af- 
fected. 

Fungus  rare. 

No  discharge  or  bleeding. 

Lasts  many  years. 

Curable. 

No  involvement  of  in- 
guinal glands,  as  a  rule. 


Encephaloid  Carcinoma 
of  Testicle. 

Ulceration  and  fungus 
common. 

Fistulse  common. 

Pain  severe  and  lanci- 
nating in  advanced 
stages. 

Soft  and  fluctuating. 

Net-work  of  large   veins 
over  surface  of  tumor. 
Attains  great  size. 


Painless  on  pressure. 

Generally  only  one  testi- 
cle affected. 

Fungus  always  present  in 
advanced  stages. 

Bleeds  freely ;  offensive 
discharge. 

Rarely  extends  beyond 
twenty  months. 

Usually  fatal. 

Inguinal,  iliac,  and  lum- 
bar glands  and  cord 
affected. 


Tubercular  Orchitis. 
Suppuration  common. 

Fistulse  common. 
Little  pain. 


At  first  hard,  knotty,  ir- 
regular. 

Skin  congested,  but  other- 
wise unaffected. 

Of  moderate  size. 


Often  painful  on  pressure. 
Often   both    testicles    af- 
fected. 
Fungus  common. 

Less   apt   to   bleed ;   dis- 
charge less  offensive. 
Lasts  several  years. 

Generally  incurable. 
Usually  no  inflammation 
of  glands. 


Lymphadenoma  sometimes  almost  exactly  simulates  syphilitic  sar- 
cocele.  It  may  involve  one  or  both  testicles.  It  usually  spares  the 
epididymis.  It  forms  an  ovoid,  hard,  indolent,  uniform  swelling.  It 
is,  however,  not  so  hard  as  syphilitic  sarcocele.  Its  surface  is  always 
smooth,  and  does  not  present  the  slight  nodulations  or  ridges  which 
are  often,  present  in  the  syphilitic  testicle.  Lymphadenoma  may  be 
found  in  other  parts  of  the  body. 

Enchondromatous  growths  may  present  areas  of  unusual  hard- 
ness ;  the  growth  is  often  much  more  rapid  and  usually  attains  much 
larger  dimensions  than  in  syphilitic  sarcocele.  Local  and  reflex  pains 
are  more  pronounced,  and  specific  treatment  is  without  avail.  How- 
ever, it  is  often  necessary  to  wait  before  diagnosis  can  be  estab- 
lished. 

In  the  acute  form  of  syphilitic  sarcocele  diagnosis  must  be  made 
by  exclusion  ;  that  is,  when  the  possibility  of  traumatism,  of  simple 
inflammation,  of  gout,  of  mumps,  of  tuberculosis,  of  continued  fevers, 
of  violent  muscular  effort,  has  been  excluded,  and    other  signs  of 


SYPHILIS  OF   THE   UKO-GENITAL  SYSTEM.  965 

syphilis  are  present,  the  syphilitic  nature  of  the  affection  may  be 
suspected. 

Syphilitic  fungus  of  the  testicle  may  be  confounded  with  ulceratmg 
carcinoma  or  tubercular  fungus.  The  ulcerating  carcinoma,  however, 
involves  the  epididymis  and  cord,  affects  the  pelvic  and  post-perito- 
neal lymphatic  glands,  forms  a  large  indolent  tumor,  gives  rise  to 
much  pain,  is  attended  with  bleeding  and  sloughing,  and  freely 
secretes  ichorous  pus.  It  runs  a  rapid  course,  and  is  attended  with 
cachexia. 

The  tubercular  fungus  differs  from  the  syphilitic  only  in  the  fact 
that  the  granulations  are  paler,  of  less  vitality,  and  not  attended  with 
infiltration  of  the  skin.     There  is  usually  cachexia. 

Prognosis. — The  prognosis  of  syphilis  of  the  testicle  is  good. 
There  is  rarely  deterioration  of  the  general  health,  or  abolition  of 
the  sexual  powers.  It  cannot  be  considered  as  indicating  a  malig- 
nant form  of  syphilis.  Although  the  disease  is  bilateral,  it  very  rarely 
produces  complete  atrophy  or  destruction.  Even  though  the  testicle 
seems  to  be  involved  as  a  whole,  some  portion  of  the  glandular  sub- 
stance is  generally  spared. 

Interstitial  orchitis,  even  if  taken  in  its  early  period,  may  be 
followed  by  atrophy.  Ulcerating  gummata  rapidly  produce  most 
extensive  destruction.  In  spite  of  the  preservation  of  virile  power, 
spermatogenesis  may  be  arrested.  Even  after  loss  of  virility  and 
fecundity,  proper  treatment  will  sometimes  restore  both. 

Treatment. — There  is  little  tendency  towards  spontaneous  cure. 
Potassium  iodide  in  full  doses  should  be  administered,  together  with 
mercury.  The  latter  drug  is  particularly  indicated  when  testicular 
manifestations  are  precocious. 

Syphilis  of  the  Vasa  Deferentia,  Seminal  Vesicles,  Pros- 
tate, Urethra,  and  Erectile  Bodies  of  the  Penis. — There  have 
been  reported  a  few  cases  of  gumma  of  the  vas,  usually  in  connection 
with  syphilitic  sarcocele.  This  structure,  together  with  the  seminal 
vesicles  and  the  prostate,  seems  to  be  singularly  free  from  the  manifes- 
tations of  tertiary  syphilis ;  at  least  clinical  evidence  of  the  frequent 
involvement  of  these  structures  is  wanting. 

Chanfre  of  the  urethra  has  been  already  described.    (See  page  110.) 

Secondary  syphilides,  particularly  the  mucous  patch,  have  been 
observed  on  the  urethral  surface.  These  occasion  a  slight  discharge, 
which  is  sometimes  mistaken  for  gonorrhoea.     (See  page  109.) 

Gummatous  ulceration  is  exceedingly  rare,  or  at  least  is  not  often 
recognized  clinically.  Its  symptoms  are  usually  confounded  with 
those  of  chronic  urethritis  from  other  causes.     It  would  be  difficult 


^QQ  GENITO-IJKINAEY   DISEASES   AND   SYPHILIS. 

io  make  the  diagnosis  except  from  urethroscopic  examination,  unless 
induration  could  be  detected  by  external  examination.  It  is  followed 
by  dense  stricture  formation. 

The  primary  and  secondary  lesions  of  the  penis  have  been  already 
described.      (See  page  827  et  seq.) 

The  erectile  bodies  of  the  penis  may  exhibit  tertiary  manifestations 
in  the  form  of  diffuse  infiltration  or  of  gummata. 

Diffuse  infiltration  particularly  involves  the  meatus  and  the  frae- 
num,  together  with  .the  mucous  membrane  of  the  prepuce  lying  to 
either  side  of  this  band.  Infiltration  may  be  either  superficial  or  deep, 
and  may  involve  a  considerable  portion  of  the  glans.  Ulceration  some- 
times follows. 

Gummata  are  usually  placed  on  the  proximal  third  of  the  caver- 
nous bodies.  They  form  small  or  large,  ovoid,  indolent,  non-inflam- 
matory, cartilaginous  tumors,  suggesting  during  their  early  development 
the  presence  of  a  foreign  body  in  the  tissues. 

Gummata  and  infiltrations  markedly  interfere  mth  erection,  making 
it  imperfect  anterior  to  the  seat  of  lesion  and  causing  bending  of  the 
organ.  They  are  obstinate  to  treatment,  and  are  scarcely  to  be  dis- 
guished  fi'om  the  plates  of  induration  resulting  from  non-specific 
cavernitis  or  fibroid  infiltrations. 

Diagnosis. — One  or  more  hard,  painless,  slowly  progressive 
nodules,  growing  in  or  from  the  erectile  tissues  of  the  penis,  showing 
no  tendency  to  ulcerate,  and  giving  rise  to  no  symptoms  other  than 
interference  with  erection,  would  be  almost  pathognomonic  of  either 
syphilis  or  non-specific  indurated  plaques.  Between  these  two  affec- 
tions the  therapeutic  test  affords  the  only  means  of  distinguishing. 

The  tertiary  manifestations,  which  closely  simulate  various  forms 
of  chancre,  are  much  more  chronic  in  their  course  than  the  primary 
lesion,  occasion  no  adenopathy,  and  begin  as  infiltrations,  which  sub- 
sequently ulcerate.  Moreover,  there  is  a  preceding  history  of  sec- 
ondary syphilis,  or  possibly  the  evidence  of  pre-existing  lesions  of 
the  disease. 

Treatment. — As  for  all  tertiaries,  the  administration  of  potassium 
iodide  and  mercury  is  indicated. 

SYPHILIS  OF  THE  OVARIES,  UTERUS,  VAGINA,  AND  VULVA. 
From  analogy  it  might  be  expected  that  syphilitic  involvement  of 
the  ovary  would  be  frequent.  Clinical  records,  however,  have  very 
little  to  advance  in  proof  of  this  theory.  It  is  probable  that  a 
sclerous  and  a  gummatous  type  of  ovaritis  occasionally  appear  as 
manifestations  of  tertiary  syphilis.     This,  however,  as  in  the  male. 


SYPHILIS   OF   THE   MAMMAKY    GLAND.  967 

occasions  no  subjective  symptoms,  follows  the  law  of  tertiary  visceral 
lesions  in  not  tending  to  ulcerate,  and  hence  escapes  notice.  Autop- 
sies have  shown  that  such  lesions  occur,  and  a  few  clinical  obser- 
vations prove,  at  least  so  far  as  the  therapeutic  test  is  concerned, 
that  some  ovarian  tumors  are  of  syphilitic  origin.  The  evidence  is 
strongly  in  favor  of  the  view  that  the  ovaries  are  far  less  subject  to 
tertiary  disease  than  are  the  testicles. 

The  Fallopian  tubes  are  involved  in  gummatous  lesions  even  more 
rarely  than  are  the  vasa  deferentia.   ■ 

The  uterus  of  syphilitic  women  is  frequently  attacked  by  endo- 
metritis, metritis,  perimetritis,  and  parametritis.  The  symptoms  and 
complications  are  the  same  as  the  homologous  non-specific  inflamma- 
tions, and  often  the  treatment  is  as  tedious  and  unsatisfactory.  There 
are  some  reported  cases  of  uterine  tumor  disappearing  rapidly  under 
the  use  of  potassium  iodide. 

The  vagina  is  very  exceptionally  the  seat  of  chancre.  Secondary 
lesions,  except  the  mucous  patch,  are  also  rare.  Tertiary  lesions  of 
the  vagina,  usually  appearing  in  the  form  of  a  diffuse  infiltration,  com- 
monly extend  from  the  vulva  or  the  rectum,  in  the  latter  case  causing 
recto-vaginal  fistulse.  Exceptionally  the  infiltrate  attacks  the  vagina 
alone.  The  symptoms  are  those  of  chronic  vaginitis,  with  marked 
thickening  particularly  of  the  posterior  wall,  often  followed  by  ulcera- 
tion and  extensive  tissue-destruction. 

The  vulva  is  a  favorite  seat  of  syphilitic  lesions  in  all  stages  of  the 
disease.  The  chancre,  secondary  syphihdes,  gummata,  and  gumma- 
tous infiltration  are  all  frequently  observed.  The  tertiary  lesions  are 
prone  to  develop  in  the  seat  of  primary  and  secondary  ulcerations. 
They  are  usually  multiple,  bilateral,  quickly  ulcerate  and  spread,  and 
produce  a  thickening  and  warty  growth  of  the  skin,  which  strongly 
suggests  elephantiasis.  In  the  debilitated  and  uncleanly  phagedsena 
develops,  with  extensive  tissue-destruction,  and,  in  case  of  healing, 
great  cicatricial  deformity. 

SYPHILIS   OF  THE   MAMMARY   GLAND. 

Chancre  about  the  nipples  is  frequently  observed,  nearly  always 
as  a  result  of  suckling  a  syphilitic  child. 

Secondary  lesions  similar  to  those  found  on  other  surfaces  of  the 
body  develop  on  the  tegument  covering  the  breast.  Papules  are 
particularly  liable  to  be  converted  into  mucous  patches  or  into  con- 
dylomata. 

Acute  irritative  mastitis  is  exceptionally  observed  in  both  men 
and  women  in  the  earliest  period  of  secondary  syphilis.     It  is  charac- 


968  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

terized  by  swelling  accompanied  by  moderate  pain  and  tenderness ; 
it  subsides  quickly,  particularly  under  specific  treatment. 

Gummatous  mastitis  may  be  diffuse  or  nodular. 

Diffuse  gummatous  mastitis  is  characterized  by  a  rather  dense  infil- 
tration involving  a  part  or  the  vv^hole  of  the  breast.  Both  breasts  may 
be  attacked  together  or  consecutively.  More  commonly  one  side  is 
involved.  If  untreated,  atrophy  and  contractions  take  place,  ulti- 
mately leaving  the  breast  wasted  and  greatly  deformed. 

The  diagnosis  from  cancerous  infiltration  may  be  extremely  diffi- 
cult, but  will  be  founded  upon  the  more  diffuse  form  of  the  syphilitic 
infiltration,  the  absence  of  lymphatic  involvement,  the  preceding  history 
of  syphilis,  and  chiefly  on  the  rapidity  with  which  symptoms  yield  to 
constitutional  treatment. 

Gummatous  nodules  of  the  breast  develop  slowly,  occasion  little  or 
no  pain,  and  are  prone  to  ulcerate  and  discharge.  There  is  found  in 
or  on  the  breast  a  hard,  painless,  non-sensitive,  freely  movable  nodule, 
which  in  a  few  weeks  has  reached  the  size  of  an  q^^^  softened,  become 
adherent  to  the  skin,  ulcerated,  and  discharged  a  turbid,  gummy  fluid. 

As  in  the  case  of  diffuse  infiltration,  these  gummata  may  lead  to 
errors  in  diagnosis.  Gummata  do  not  retract  the  nipple,  they  com- 
monly develop  before  the  age  of  cancer,  and  they  ulcerate  in  a  different 
way  from  typical  malignant  growths.  Usually  the  lymphatic  glands 
are  not  involved,  and  a  history  or  signs  of  syphilis  are  obtainable. 

Specific  treatment  ordinarily  accomplishes  prompt  resolution  of 
tertiary  manifestations  in  the  breast,  and  is  the  main  test  upon  which 
a  differential  diagnosis  must  be  founded. 

THE    PROGNOSIS    OF    SYPHILIS. 

Most  of  the  deaths  in  syphilitics  are  from  intercurrent  tuberculosis. 
Crippling  sequelae  of  the  primary  and  secondary  disease  are  in  inverse 
proportion  to  the  efficiency  of  treatment.  When  tertiaries  recur,  in- 
termittent treatment  should  be  continued  for  many  years. 

The  mortality  of  syphilis  is  due  to  its  tertiary  lesions.  Aneurism, 
arterio-sclerosis,  tabes  dorsalis,  general  paresis,  cirrhosis  of  the  liver, 
and  kidney  diseases  are  the  common  causes  of  death.  Seventy-five 
per  cent,  of  tabes  are  due  to  syphilis.  Bramwell  has  noted  that  in 
seventeen  of  thirty-two  cases  of  fatal  tabes  in  which  the  exact  date  of 
syphilitic  infection  was  known  the  expectation  of  life  was  diminished 
an  average  of  nearly  sixteen  years  for  each  patient.  Even  a  greater 
percentage  of  cases  of  general  paresis  are  of  specific  origin,  the  average 
duration  of  expected  life  being  diminished  in  each  case  by  twenty 
years.     This  disease  runs  its  fatal  course  in  from  two  to  six  years. 


CHAPTER   XXVII. 

SYPHILITIC    HEREDITY. HEREDITARY    SYPHILIS. 

Syphilis  is  transmitted  not  as  a  tendency  or  predisposition,  but  as 
an  active  contagious  disease.  It  may  reach  the  child  (1)  by  descent 
from  the  father ;  (2)  by  descent  from  the  mother ;  (3)  by  descent  from 
both  parents  (mixed  heredity) ;  (4)  by  direct  infection. 

Descent  from  the  father,  or  seminal  transmission,  is  far  more 
frequent  than  maternal  descent.  It  represents  the  simplest  form  of 
heredity,  since  the  influence  of  the  father,  so  far  as  the  child  is  con- 
cerned, ceases  when  impregnation  is  accomphshed.  Provided  there 
are  no  lesions  of  the  genital  tract  causing  a  contagious  discharge  to 
mingle  with  the  sperm,  the  latter,  if  inoculated  upon  a  healthy  per- 
son, win  not  cause  the  development  of  chancre  ;  it  is  as  free  from 
contagious  properties  as  other  normal  secretions  ;  yet  when  fertilizing 
the  ovum  it  carries  with  it  the  syphilitic  infection. 

In  the  florid  stage  of  a  virulent  syphiKs  the  disease  is  most  likely 
to  be  transmitted,  A  child  may,  however,  be  born  healthy  even 
under  such  circumstances.  On  the  other  hand,  a  father  who  has  been 
free  from  symptoms  of  syphilis  for  years  may,  as  a  rare  exception, 
beget  a  child  exhibiting  a  virulent  form  of  the  hereditary  disease. 

Descent  from  the  mother  may  be  due  (1)  to  infection  previous 
to  conception,  or  (2 1  to  infection  occurring  at  this  time,  or  (3)  to  post- 
conceptional  infection. 

Maternal  descent  is  more  certain  and  is  more  potent  in  its  influences 
for  harm  than  is  that  from  the  father,  since  the  blighting  effect  of  an 
ovarian  infection  is  reinforced  by  the  devitahzing  influences  of  a 
maternal  dyscrasia. 

When  the  mother  is  infected  at  the  moment  of  conception  the 
cast  becomes  in  reality  an  example  of  paternal  heredity,  since  the 
germ  is  syphilitic  not  because  the  ovule  of  the  mother  is  infected,  but 
because  of  the  diseased  spermatozoa  of  the  father.  During  the  period 
of  intra-uterine  life  the  syphilis  acquired  by  the  mother  develops 
and  exercises  its  malign  influence  upon  blood  and  the  general  nutri- 
tion, thus  further  affecting  the  already  diseased  foetus :  hence  syphilis 
inherited  under  such  circumstances  is  particularly  hable  to  be  severe. 
Moreover,  there  are  distinct  placental  lesions  which  aggravate  the 
tendency  to  abortion  and  still-birth, 

969 


970  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

In  consequence  of  cell  proliferation  in  the  villi  the  vessels  are 
compressed  and  fmahy  obliterated,  and  the  vascular  spaces  into 
which  the  villi  dip  often  disappear.  The  epithelium  is  also  thickened, 
and  thus  there  is  material  interference  v^ith  the  interchange  between 
maternal  and  foetal  blood.  If  this  process  is  generally  diffused  over 
the  placenta,  the  foetus,  of  course,  perishes.  If  it  is  partial,  the  foetus 
may  live  for  a  varying  length  of  time,  but  will  exhibit  the  signs  of  mal- 
nutrition.    The  earlier  the  foetus  is  infected  the  more  serious  the  results. 

Maternal  heredity,  most  potent  in  the  first  year  of  syphilis,  gradu- 
ally becomes  attenuated ;  but  even  in  the  later  periods  transmission 
is  much  more  likely  to  occur  than  it  is  from  paternal  syphihs  of  the 
same  stage. 

Neumann,  as  the-  result  of  a  statistical  study,  shows  that  two- 
thirds  of  the  cases  of  germinal  syphilis  perish  either  in  utero  or 
shortly  after  birth. 

Post-conceptional  syphihs — that  is,  infection  of  the  mother  during 
the  period  of  utero-gestation — may  be  transmitted  to  the  foetus  up  to 
the  eighth  month.  After  that  it  is  probable  that  the  child  will  escape, 
although  cases  are  reported  showing  that  chancre  acquired  in  a  woman 
as  late  as  the  eighth  month  has  been  followed  by  syphilis  of  the  child. 

Syphihs  derived  from  the  mother  healthy  at  the -time  of  concep- 
tion but  contracting  the  disease  during  the  period  of  gestation,  and 
infecting  the  foetus  through  the  placental  circulation,  is  not  classed  by 
Fournier  as  hereditary  syphihs,  since  under  these  circumstances  the 
healthy  ovule  impregnated  by  healthy  spermatozoa  inaugurates  a 
normal  growth  not  interfered  with  till  it  is  well  advanced.  Lesions 
are,  therefore,  less  severe  than  they  are  when  the  germinal  cells  are 
diseased. 

Mixed  Heredity. — When  at  the  time  of  conception  both  parents 
are  suffering  from  syphilis  in  its  early  stages,  the  disease  is  almost 
certain  to  be  transmitted,  and  usually  in  a  lethal  form. 

The  relative  gravity  of  the  three  forms  of  descent  is  expressed  by 
Fournier's  tabulation,  based  on  five  hundred  observations.  Among 
the  cases  of  paternal  heredity  twenty-eight  per  cent,  died,  and  thirty- 
seven  per  cent,  showed  lesions  of  syphihs.  Among  the  cases  of  ma- 
ternal heredity  sixty  per  cent,  died,  and  eighty-four  per  cent,  showed 
lesions  of  syphihs.  Mixed  heredity  caused  sixty-eight  and  a  half  per 
cent,  of  deaths,  and  lesions  in  ninety-two  per  cent.  These  estimates 
demonstrate  that  paternal  heredity,  though  more  frecjuent  than  the 
other  forms,  is  less  than  half  as  communicable  or  fatal  as  is  maternal 
heredity,  and  that  the  latter  is  less  virulent  in  its  effects  than  mixed 
heredity.' 


SYPHILITIC   HEEEDITY.  971 

Direct  infection  implies  inoculation  of  the  child  during  parturi- 
tion by  the  contagious  discharges  of  secondary  vaginal  or  vulvar 
lesions  of  the  mother.  This  cannot  be  classed  as  hereditary  syphilis. 
There  seems  to  be  no  reason  why  such  infection  should  not  excep- 
tionally take  place,  provided  the  mother  is  suffering  from  active  genital 
lesions  acquired  too  late  to  affect  the  child  in  utero.  That  there  is 
lacking  a  sufficient  number  of  entirely  satisfactory  reports  of  such 
infection  to  prove  conclusively  that  it  exists  would  seem  to  show 
that  the  child  has  acquired  a  certain  immunity  somewhat  similar  to 
that  expressed  by  Cohes's  law ;  in  other  words,  that  it  either  has  a 
latent  modified  form  of  the  disease,  or,  from  antitoxin  absorption 
from  the  mother's  blood,  has  ceased  to  be  susceptible  to  it. 

Syphihs  thus  conveyed  would  be  acquired,  not  inherited,  and 
would  begin  with  the  primary  sore. 

The  Period  of  Syphilitic  Heredity. — It  is  universally  conceded 
that  hereditary  syphilis  becomes  milder  in  type  and  less  likely  to  be 
transmitted  in  proportion  to  the  age  of  the  disease  of  the  parents. 
Heredity  istmost  potent  and  virulent  in  its  first  year.  There  is  a 
rapid  attenuation  in  the  third  year,  after  which  the  influence  of  the 
disease  as  expressed  by  transmission  still  diminishes,  but  at  a  slower 
rate.  In  the  large  majority  of  cases  there  comes  a  time  when  syphilis 
is  no  longer  transmissible.  This  rule,  however,  is  subject  to  excep- 
tions, although  it  is  true  that  tertiary  or  late  symptoms  of  syphilis 
are  non-contagious,  and  probably  sequelse  of  the  lesions  of  the  active 
period  of  the  disease.  The  question  as  to  transmission  years  after 
the  original  outbreak,  and  in  the  absence  of  all  signs  or  symptoms 
of  the  disease  in  the  parents,  is  important.  Such  transmission  is 
possible,  and  is,  perhaps,  more  common  than  is  generally  supposed. 
Fournier  states  that  of  five  hundred  and  sixty-two  cases  of  heredi- 
tary syphilis,  in  sixty  the  disease  was  transmitted  more  than  six  years 
after  the  primary  infection.  Apparently  carefully  observed  cases  are 
recorded  pointing  to  heredity  from  parents  in  the  fifteenth  and  even 
in  the  twentieth  year  of  syphilis. 

Treatment  exercises  upon  the  heredity  of  syphilis  a  more  power- 
ful effect  than  time  alone.  Thus,  Fournier  shows  that  after  the 
exhibition  of  the  specifics  the  mortality  in  maternal  heredity  is  re- 
duced from  fifty-nine  per  cent,  to  three  per  cent.,  and  that  children 
born  living  are  usually  free  from  signs  of  syphihs. 

The  type  of  parental  syphilis  does  not  necessarily  indicate  that  of 
the  inherited  disease.  Heredity  in  its  most  malignant  form  may  de- 
stroy the  offspring  of  parents  suffering  from  mild  syphilis,  and,  con- 
versely, virulent  outbreaks  in  the  parents  may  not  interfere  with  the 


972  GENITO-UEINAKT  DISEASES  AND   SYPHILIS. 

birth  of  children  either  but  slightly  affected  or  absolutely  healthy : 
hence  it  is  unsafe  to  base  prediction  as  to  the  type  of  inheritance 
upon  the  type  of  disease  of  the  parents. 

Conceptional  syphilis  is  that  acquired  by  the  healthy  mother 
from  a  foetus  infected  by  the  father.  In  the  vast  majority  of  cases 
maternal  syphilis  is  acquired  by  the  mother  from  direct  absorption  of 
the  poison  through  a  breach  of  surface,  the  first  manifestation  of  disease 
then  being  a  chancre,  which  is  followed  by  a  train  of  secondary  and  ter- 
tiary symptoms.  She  can,  however,  also  acquire  syphilis  through  the 
medium  of  the  placental  circulation  of  a  child  seminally  infected  by 
the  father.  This  method  of  contagion,  long  ciuestioned,  is  amply 
proved.  Thus,  there  are  many  reported  cases  showing  that  even 
though  the  father  is  free  from  discoverable  lesions  at  the  time  of 
conception,  and  there  is  no  history  or  trace  of  a  primary  lesion  in  the 
woman,  yet  she  may  exhibit  the  phenomena  of  syphilis.  Provided 
both  husband  and  wife  are  really  free,  the  one  from  contagious  lesions, 
the  other  from  evidence  of  the  present  or  previous  primary  sore,  it 
Avill  often  be  found  that  the  woman  has  either  been  delivered  of  a 
syphilitic  child  or  has  had  an  abortion  or  a  miscarriage  some  time 
before  the  outbreak  of  the  symptoms  of  the  disease, 

Colles's  law,  which  states  that  a  child  begotten  by  a  syphilitic 
father  and  born  of  an  apparently  healthy  mother  cannot  infect  her, 
even  though  it  exhibit  venereal  ulcers  on  the  hps  and  tongue  and  in 
suckling  cause  cracks  and  fissures  in  the  mother's  nipple,  was  for- 
merly regarded  as  a  positive  proof  that  the  mother  of  a  syphilitic 
child  was  always  herself  syphilitic,  since  only  in  this  way  could  her 
immunity  be  explained. 

Diday  applies  to  the  explanation  of  this  well-known  phenomenon 
Pasteur's  discovery  that  methodical  repetition  of  inoculation  attenu- 
ates and  ultimately  neutralizes  the  virus  of  disease.  This  is  shown 
when  animals  are  repeatedly  inoculated  with  the  virus  of  hydro- 
phobia. When  a  woman  bears  a  syphilitic  child  the  blood  freely 
circulating  between  mother  and  foetus  becomes  a  vehicle  for  repeated 
inoculation  of  the  attenuating  fluid,  and  the  mother  is  rendered 
proof  against  syphilis  by  seven  or  eight  months  of  perfected  Pas- 
teurization. 

Conceptional  syphihs  may  appear  in  one  of  tw^o  forms : 

1.  The  woman  may  immediately  after  conception  become  languid, 
weak,  and  emaciated,  complaining  of  headaches,  rheumatic  pains,  sleep- 
lessness, and  all  the  symptoms  of  neurasthenia.  Miscarriage  occurs,  and 
from  this  she  rallies  very  slowly.  Subsequent  pregnancies  take  much 
the  same  course,  the  miscarriages  coming  later  in  the  period  of  gesta- 


SYPHILITIC    HEKEDITY.  973 

tion.  Then  living  but  syphilitic  children,  and  finally  healthy  children, 
are  born. 

In  many  cases  undoubted  tertiary  symptoms  appear,  such  as 
gumma  or  periostitis.  All  these  symptoms  are  usually  rapidly  cured 
by  specific  treatment. 

2.  The  woman  may  remain  apparently  well,  being  delivered  at 
about  full  term  of  a  child  which  either  at  birth  or  shortly  after  ex- 
hibits the  characteristic  lesions  of  hereditary  syphilis.  Experimental 
inoculatioD  of  such  a  mother  with  active  virus  will  not  produce  chancre. 
She  is  immune  against  syphilis,  either  because  she  has  the  disease  in 
a  latent  form  or  because  of  the  protective  action  of  antitoxins. 

The  question  as  to  why  in  some  cases  the  mother  exhibits  the 
symptoms  and  lesions  of  syphilis  and  in  others  shows  no  sign  of  the 
disease  except  the  immunity  expressed  by  Colles's  law  is  still  un- 
answered. An  ingenious  and  satisfactory  theory,  but  one  still  un- 
proved, explains  this  difference  on  the  ground  that  the  unbroken 
placenta  proves  an  insuperable  obstacle  to  the  migration  of  the  specific 
germ,  but  allows  the  antitoxins  to  filter  freely  :  hence  the  mother  be- 
comes immunized  without  contracting  the  disease.  When  through 
injury  or  other  cause  lesions  of  the  placenta  allow  the  maternal  and 
the  foetal  blood  directly  to  intermingle,  the  mother  receives  into  her 
circulation  not  only  the  antitoxins  but  also  the  active  living  germs : 
hence  she  develops  the  disease,  possibly  in  an  attenuated  form  because 
of  the  continued  antitoxin  absorption.  The  same  reasoning  applies  in 
the  explanation  of  the  immunity  of  the  apparently  healthy  children 
of  syphilitic  parents  from  contracting  the  disease.  (Profeta's  law.) 
In  the  great  majority  of  cases  this  is  because  they  already  have 
syphilis  in  an  active  or  a  latent  form.  In  the  case  of  seemingly 
healthy  children  of  tainted  heredity  there  may  have  been  antitoxin 
absorption  from  the  mother  without  infection  by  the  germ. 

Syphilis  and  Marriage. — The  prevalence  of  acquired  syphilis, 
the  frequency  with  which  it  is  transmitted,  the  severity  of  its  lesions, 
and  its  crippling,  deforming,  and  often  fatal  effects  when  it  is  in- 
herited, make  questions  pertaining  to  the  marriage  of  syphilitics  of 
cardinal  importance.  Opinions  upon  this  subject  should  be  clear  and 
decided. 

From  what  already  has  been  said  it  is  obvious : 

1.  That  syphilis  is  most  apt  to  be  inherited  from  parents  who  at 
the  time  of  conception  are  in  their  first  year  of  the  disease.  The 
aptitude  is  greatest  when  both  parents  are  syphilitic,  is  slightly  less 
when  the  mother  alone  is  affected,  and  is  diminished  more  than  half 
when  the  father  alone  is  affected. 


974  GENITO-UEINAET   DISEASES   AND   SYPHILIS. 

2.  That  the  tendency  toward^  heredity  becomes  rapidly  less  from 
the  first  to  the  third  year,  and  after  the  fourth  year  is  rarely  manifested. 

3.  That  time  in  conjunction  with  vigorous  continued  specific  treat- 
ment so  affects  the  tendency  to  heredity  that  after  the  fourth  year  it 
is  practically  brought  to  the  vanishing-point. 

4.  That  time  and  vigorous  treatment  combined  cannot  always  pre- 
vent the  transmission  of  syphilis  by  heredity.  The  instances  in  which 
such  transmission  has  occurred  after  four  years,  in  spite  of  active 
treatment,  are,  however,  so  few  that  they  properly  can  be  rejected  in 
considering  syphihs  and  marriage. 

The  logical  deduction  from  the  foregoing  summary  is  that  men 
who  have  syphilis  which  has  been  treated  carefully  for  four  years  can 
marry  and  will  have  healthy  children.  When  the  woman  is  syphi- 
litic, or  both  the  man  and  the  woman  have  contracted  syphilis,  it 
would  be  safer  to  avoid  conception  till  after  a  longer  period. 

Prognosis  of  Syphilitic  Heredity. — When  conception  takes 
place  during  the  early  secondary  period  of  syphilis  the  usual  result  is 
abortion,  occurring  from  the  first  to  the  fifth  or  sixth  month,  the  foetus 
sometimes  exhibiting  the  evidences  of  syphihs  in  the  shape  of  large 
bullae  upon  the  palms  and  soles,  or  other  characteristic  lesions,  but 
quite  often  showing  nothing  distinctive.  Later,  when  the  virulence  of 
the  disease  of  the  parents  is  lessened  by  time,  either  abortion  occurs 
when  pregnancy  is  more  advanced,  or  live  children  are  brought  into 
the  world  which  at  birth  or  afterwards  show  signs  of  syphilis.  One- 
fourth  of  these  die  within  the  first  six  months.  If  they  survive  that 
period  the  chances  for  life  are  slightly  in  their  favor,  but  the  chances 
for  health  or  freedom  from  disease  are  overwhelmingly  against  them. 
Fournier  states  that,  in  general,  the  chances  of  transmission  are  fifty 
in  the  hundred,  and  that  the  infant  mortality  is  forty-two  per  cent. ; 
in  hospital  practice  this  mortality  percentage  is  doubled. 

When  the  question  of  prognosis  is  considered  in  regard  to  indi- 
vidual cases,  it  is  safe  to  predict  healthy  children  from  parents  who 
at  the  time  of  conception  are  past  the  fourth  year  of  syphilis  and 
have  been  persistently  treated.  Even  after  two  years  in  the  very  great 
majority  of  cases  the  same  outlook  is  justifiable.  In  the  first  year 
prognosis  in  this  respect  must  be  more  guarded ;  but,  provided  the 
mother  is  actively  treated  during  the  whole  period  of  utero-gestation, 
the  child  will  probably  be  born  healthy.  Exceptionally  families  show 
an  inveterate  tendency  to  heredity  little  influenced  by  time  and  treat- 
ment. Fournier  quotes  a  case  of  nineteen  pregnancies  each  resulting 
in  still-birth.  In  speaking  of  the  prophylaxis  of  hereditary  syphilis, 
he  earnestly  advises  that  a  man  who  has  been  infected  with  the  dis- 


HEREDITARY    SYPHILIS.  975 

ease  should  be  forbidden  marriage  till  time  and  treatment  have  ac- 
complished their  depurative  work,  and  should  be  shown  without 
mitigation  and  without  exaggeration  the  evils  which  may  result  from 
sexual  intercourse.  He  should  be  told  that  he  may  infect  his  wife 
directly  by  sexual  contact,  or  indirectly  through  the  medium  of  the 
foetus,  and  that,  if  she  fails  to  abort,  she  may  deliver  at  term  a  Avizened, 
deformed,  blotchy  child,  which  if  it  lives  may  show  the  stunted 
development  and  mental  incapacity  so  characteristic  of  hereditary 
syphilis. 

When,  in  spite  of  warnings,  it  is  probable  that  sexual  life  is  con- 
tinued, the  man  should  be  subjected  to  the  most  rapid  and  efficient 
treatment  applicable.  When  conception  has  taken  place  from  a 
syphilitic  father,  whether  the  mother  has  or  has  not  the  disease,  she 
should  receive  active  specific  treatment  during  the  whole  period  of 
utero-gestation. 

HEREDITARY   SYPHILIS. 

Hereditary  syphilis  differs  from  the  acquired  disease  in  being 
constitutional  from  the  first.  There  is  no  primary  stage, — that  is, 
there  is  no  chancre, — nor  in  the  course  of  its  development  can  the 
manifestations  of  the  disease  be  classed  under  periods.  They  may 
correspond  in  type  to  secondary  or  tertiary  lesions,  but  a  chrono- 
logical order  such  as  is  observed  in  acquired  syphilis  is  wanting.  For 
the  first  two  years  after  birth  secondary  and  tertiary  manifesta- 
tions appear  side  by  side.  Later,  at  about  the  time  of  puberty,  for 
instance,  if  lesions  appear,  they  belong  exclusively  to  the  tertiary 
type. 

The  local  expressions  of  hereditary  syphilis  correspond  closely 
with  those  already  described  as  characteristic  of  the  acquired  disease. 
Thus,  the  syphilides  are  pathologically  and  clinically  the  same,  and 
this  is  true  of  visceral  involvements.  The  main  point  of  difference 
hes  in  the  profound  alteration  which  syphilis  in  its  hereditary  form 
impresses  on  general  nutrition  and  development. 

In  a  certain  proportion  of  cases  the  characteristic  symptoms  of 
hereditary  syphilis  develop  at  birth  or  within  a  few  days  of  this  time. 
Often  the  child  remains  apparently  healthy  for  a  period  of  from  three 
to  five  weeks,  manifestations  of  syphilis  then  appearing.  It  seems  well 
substantiated  that  a  child  may  be  born  healthy  and  may  show  no  symp- 
toms of  syphihs  for  several  years,  after  which  time  typical  tertiary 
lesions  may  develop.  In  many  of  these  cases  it  is  probable  that  the 
post-natal  lesions  were  so  feAV  and  slight  that  they  were  not  observed. 
The  form  of  the  disease  developing  more  than  three  years  after  birth 
Fournier  called  late  hereditary  syphilis. 


976  GENITO-UEINAEY  DISEASES   AND   SYPHILIS. 

The  typically  syphilitic  child  is  at  birth  a  wasted,  wizened,  snuf- 
fling, feeble  creature,  with  a  weak,  hoarse  cry,  often  exhibiting  a  bul- 
lous eruption  of  the  skin.  It  has  been  blasted  ah  initio,  presenting  the 
appearance  of  an  advanced  stage  of  marasmus.  The  skin  is  harsh, 
non-elastic,  and  gray  or  dirty  yellow  in  color ;  its  appendages — the 
eyelashes,  eyebrows,  hair,  and  nails — also  show  imperfect  or  per- 
verted development.  The  muscles  are  wasted.  The  general  condition 
is  well  expressed  by  the  term  atrophia  neonatorum,  which,  though  it 
may  result  from  a  number  of  prenatal  causes,  reaches  its  most  striking 
development  in  hereditary  syphilis.     Such  children  rarely  survive. 

When  the  influence  of  heredity  is  manifested  in  a  less  virulent 
form  the  child  may  be  born  properly  developed  and  apparently  well 
nourished.  In  a  few  weeks  lesions  of  the  skin,  mucous  membranes, 
and  eyes  develop,  corresponding  in  type  to  the  expressions  of  acquired 
secondary  syphilis  ;  these  are  frequently  associated  with  infiltrations  of 
the  viscera  and  bones,  which  pathologically  belong  to  tertiary  syphilis. 

Following  the  first  outbreak  there  is  an  intermediary  period,  lasting 
a  year  or  eighteen  months,  till  second  dentition,  till  puberty,  or  even 
through  life.  It  is  mainly  characterized  by  absence  of  symptoms. 
The  general  expression  of  the  syphilitic  diathesis  is  present,  marked 
possibly  by  malnutrition,  retarded  development,  wizened  face,  and 
sunken  nose,  but  there  seems  to  be  little  tendency  towards  renewed 
outbreaks  of  secondary  lesions. 

The  tertiary  stage,  corresponding  to  the  tertiary  period  of  the 
acquired  disease,  manifests  itself  at  the  period  of  second  dentition, 
about  the  time  of  puberty,  or  towards  the  end  of  middle  life.  Its 
lesions  may,  of  course,  develop  at  any  time,  and  it  may  remain  latent 
to  the  age  of  sixty  (Fournier). 

SKIN   AND    MUCOUS    MEMBRANE   LESIONS   OF    HEREDITARY   SYPHILIS. 

These  correspond  in  general  with  those  of  acquired  syphilis,  but 
are  more  severe,  and  at  times  appear  in  the  form  of  diffuse  infiltra- 
tions. They  vary  somewhat  in  accordance  with  their  time  of  appear- 
ance after  birth.  Those  which  are  found  at  birth  are  most  pro- 
nounced. Thus,  it  IS  not  infrequent  to  observe  a  pemphigus  so 
extensive  that  a  greater  part  of  the  epidermis  is  involved  and  is  shed 
in  large  strips.  The  mucous  membrane  is  similarly  affected  at  the 
same  time.  The  lesion  at  birth  may  be  pustular  or  ulcerative  in  type. 
In  either  case  the  arrest  of  development,  hoarse  voice,  snuffles,  and 
other  signs  of  the  disease  are  usually  characteristic. 

When  the  child  is  born  apparently  healthy,  the  symptoms  not  de- 
veloping ,for  some  weeks,  the  skin  eruption  is  commonly  erythematous 


HEREDITARY  SYPHILIS.  977 

and  papular  in  type,  at  least  primarily,  and  coincidently  with  its 
appearance  snuffles,  sore  mouth,  hoarse  voice,  and  general  emaciation 
are  noted. 

Erythematous  (roseolar)  syphilides  differ  from  those  of  the 
adult  only  in  the  fact  that  the  epithelial  layer  of  the  skin  is  more  readily 
macerated,  particularly  where  the  integument  is  creased  or  folded,  as 
about  the  neck,  the  genitalia,  or  the  buttocks,  and  there  results  an 
abraded  surface,  presenting  the  appearance  of  a  mucous  patch. 

Syphilitic  roseola  is  apt  to  develop  about  the  second  or  third 
week  after  birth,  and  first  appears  on  the  body  in  the  form  of  small, 
oval,  rounded,  or  irregular  spots,  dull  red  in  color,  and  disappearing 
upon  pressure. 

Sometimes  the  eruption  is  confluent,  covering  large  areas,  with  an 
almost  unbroken  sheet  of  dull  red  color. 

It  is  frequently  placed  about  the  genitalia  and  on  the  face,  thus 
differing  from  acquired  syphilitic  roseola. 

The  diagnosis  of  syphilitic  roseola  is  sometimes  difficult,  as  it  may 
closely  resemble  simple  erythema.  The  progress  of  the  disease  to  the 
formation  of  papules,  becoming  scaly  on  the  palms  and  soles,  and 
the  prompt  yielding  to  mercurial  treatment  are  characteristic  features 
of  syphilis. 

Papular  Syphilides  and  Mucous  Patches. — These  lesions  are 
most  marked  upon  the  buttocks,  palms,  soles,  and  face,  but  may  be 
diffused  over  the  entire  body.  The  small  papules  are  situated  in 
groups,  sometimes  rounded,  more  often  irregular  in  shape,  and  tend 
to  coalesce  and  form  broad,  flat  papules.  In  the  corners  of  the  mouth 
they  are  converted  into  painful,  bleeding  fissures,  which  on  healing 
leave  permanent  scars.  These  scars  serve  a  useful  diagnostic  purpose 
in  later  life.  Exfoliation  is  most  marked  in  the  plantar  and  palmar 
papular  syphilides,  which  when  confluent  may  cause  the  epidermis 
to  be  shed  in  large  strips,  exposing  a  thick,  raw-ham-colored  infiltra- 
tion of  the  true  skin.  This  corresponds  in  type  to  the  plantar  and 
palmar  psoriasis  of  acquired  syphilis,  and  may  be  complicated  by  pain- 
ful cracks  or  fissures. 

Papules  when  exposed  to  heat  and  moisture,  as  in  the  folds  of  the 
buttocks,  lose  their  surface  epithelium  by  maceration,  become  excori- 
ated, and  cause  an  offensive  discharge.  These  mucous  patches  are 
formed  most  commonly  about  the  anus  or  the  angles  of  the  mouth. 
Neumann  states  that  they  never  exhibit  the  papfllary  overgrowth  so 
common  in  the  acquired  disease. 

The  papular  form  of  hereditary  syphilide  is  much  more  obstinate 
to  treatment  than  is  the  roseolar  form  of  the  disease. 

62 


978 


GEIS'ITO-UEIXAKY  DISEASES  ANT>   SYPHILIS. 


Vesicular  syphilide  appearing  in  the  form  of  small  discrete  blebs 
is  usually  associated  with  the  papular  and  papulo-pustular  lesions. 
"\Mien  the  individual  vesicles  are  large,  their  contents  soon  become 
purulent.  The  small  vesicles  are  grouped,  and  are  placed  on  in- 
durated papules.  The  eruption  is  rare,  and  is  often  a  sign  of  severe 
infection. 

Pustular  Syphilide. — The  lesions  of  this  syphiloderm  commonly 
succeed  the  papular  eruption,  though  they  may  be  noted  at  birth  or 
may  develop  as  the  first  symptoms.  Frequently  they  do  not  appear 
until  several  years  after  the  first  outbreak. 

The  pustules  vary  in  number,  size,  and  depth  in  accordance  with 
the  severity  of  the  disease.  They  are  most  frequently  seen  on  the 
buttocks,  thighs,  scalp,  face,  hands,  and  soles,  and  are  said  to  indicate 
the  probability  of  late  tertiary  outbreaks. 

As  in  the  adult,  the  pustular  eruption  may  take  the  form  of  acne, 
impetigo,  or  ecthyma.  Sj^hilitic  impetigo  is  most  frequent  on  the 
face  and  scalp.  The  axillary  and  inguinal  regions  are  also  seats  of 
preference.  Distinct,  often  deep,  ulceration  beneath  the  crusts,  and 
copper-colored  infiltration  of  the  periphery  of  the  lesion,  differentiate 
the  sj'philitic  affection  from  simple  impetigo.  Syphilitic  ectMmia 
attacks  the  buttocks  and  thighs  by  preference,  forming  large,  flat, 
infiltrated  pustules,  the  thick  crusts  of  which  conceal  deep  ulcers. 

Nearly  all  these  pustular  lesions  leave  permanent  scars ;  they  may 
be  complicated  by  cellulitis  and  gangrene,  leading  to  wide-spread 
destruction  of  the  skin. 

Bullous  Syphilide. — The  bullous  syphiloderm  or  pemphigus 
commonly  appears  on  the  soles,  palms,  fingers,  toes,  or  limbs.  The 
eruption  consists  of  blebs  more  or  less  irregularly  distended  with 
liquid,  which  may  be  clear,  cloudy,  or  bloody.  It  begins  as  dark,  cir- 
cumscribed infiltrates,  from  which  the  epidermis  is  shortly  raised  in 
the  form  of  blebs. 

These  blebs  are  circular  or  oval  in  shape,  sometimes  irregular,  are 
seated  on  inflamed  reddish  skin,  are  surrounded  by  a  slight  areola, 
and  have  a  tendency  to  become  confluent  and  spread.  When  a  child 
exhibits  such  an  eruption  at  birth  or  mimediately  after,  the  presence 
of  syphilis  should  be  strongly  suspected,  and  will  be  quite  certain  if, 
in  conjunction  with  the  pemphigus,  the  general  cutaneous  surface  is 
yellow  or  muddy  in  hue,  is  without  elasticity  or  softness,  owing  to  the 
absence  of  subcutaneous  fat,  and  is  for  the  same  reason  so  furrowed 
and  wrinkled  about  the  face  that  the  child  presents  an  appearance 
of  senility,  and  if  there  are  also  other  syphilitic  skin-lesions  and  the 
child  has  snuffles  and  a  hoarse  cry. 


HEREDITARY   SYPHILIS. 


979 


The  appearance  of  pemphigus  is  ominous,  denoting  an  extreme 
degree  of  poisoning  by  the  syphilitic  virus. 

When  the  bullae  of  pemphigus  are  filled  with  serum  deeply  stained 
with  blood,  there  may  be  an  associated  hemorrhagic  syphilis, — that  is, 
a  form  of  the  disease  characterized  by  a  purpuric  eruption,  by  bleed- 
ing from  the  mucous  membrane  of  the  nose,  mouth,  and  gastro-intes- 
tinal  tract,  and  by  visceral  hemorrhages.  The  bleeding  is  due  to 
syphilitic  degeneration  of  the  blood-vessels,  especially  the  veins  and 
capillaries.  These  hemorrhages,  usually  multiple  and  slight,  are  most 
likely  to  occur  just  after  birth,  at  the  time  the  cord  is  tied.  Such 
cases  are  almost  invariably  fatal. 

Tubercular  and  Guramatous  Syphilides. — Tubercular  and 
gummatous  lesions  may  appear  at  any  age,  but  are  most  common 
from  the  tenth  to  the  twenty-ninth  year.  They  may  assume  the  dry 
or  the  ulcerative  form,  and  usually  exhibit  a  circular  or  circinate 
grouping.     There  is  commonly  but  a  single  group.     The  seats  of  pre- 


FiG.  312. 


Tubercular  and  gummatous  ulceratiou  of  hereditary  syphilis. 

dilection  are  the  face,  particularly  the  nose,  and  the  anterior  surface 
of  the  leg.  They  appear  in  the  form  of  painless,  slowly  increasing, 
raw-ham-colored  infiltrations,  which  commonly  ulcerate  and  are  cov- 
ered with  thick  crusts.    These  ulcers  may  heal,  or  may  slowly  extend, 


980  GENITO-UEINAEY   DISEASES  AND   SYPHILIS. 

forming  phagedenic  or  serpiginous  lesions.  Non-ulcerating  infiltra- 
tions absorb,  leaving  atrophic  areas ;  the  ulcerating  lesions  leave  de- 
forming cicatrices :  hence  the  importance  of  early  recognition  and 
prompt  treatment  of  these  syphilides.  They  closely  resemble  lupus, 
particularly  w^hen  the  face  is  attacked.     (Fig.  312.) 

Diagnosis. — The  differential  diagnosis  betv^een  dry  tubercular 
syphilide  and  non-ulcerating  lupus  is  founded  upon  the  dusky-red 
color  of  the  syphilide  and  the  firm  induration.  Tubercular  nodules 
exhibit  a  more  translucent,  yellowish  red,  and  are  more  yielding  to 
pressure.     (Fournier.) 

The  differential  diagnosis  between  the  ulcerating  syphilides  and 
lupus  (Fournier)  is  founded  upon : 

1.  Areola. — The  areola  of  the  syphilide  is  dusky  red,  that  of  the 
scrofulide  is  lighter,  sometimes  of  a  bluish  tint. 

2.  Crusts. — Those  of  the  syphilides  are  more  homogeneous,  more 
compact,  thicker,  and  harder  than  those  of  the  scrofulides.  They  are 
more  frequently  stratified  and  more  deeply  colored,  almost  black  or 
greenish  black. 

3.  The  Borders  of  the  Lesion. — In  syphilides  these  are  always 
sharply  marked,  elevated,  infiltrated,  punched  out,  and  adherent.  In 
lupus  they  are  less  distinctly  outlined,  are  flat,  soft,  often  reduced  to  a 
simple  ulcerating  circumference.  They  are  not  punched  out,  and  are 
often  loose  and  undermined. 

4.  The  Base  of  the  Ulcer. — In  tertiary  syphilis  this  is  deep,  irregular, 
anfractuous,  and  exhibits  a  yellowish,  adherent,  semi-sohd  covering, 
representing  the  necrosed  gummatous  infiltrate.  Lupus  shows  ulcera- 
tion more  on  a  level  with  the  surrounding  surface,  with  cherry-red 
granulations,  sometimes  exuberant,  sometimes  presenting  a  smooth 
glistening  surface. 

5.  Configuration  of  the  Lesion. — Often,  but  not  invariably,  the 
syphilitic  lesions  form  a  complete  circle,  a  portion  of  a  circle,  or  ser- 
pentine undulations.     The  ulcers  of  lupus  are  more  irregular. 

It  is  not,  however,  on  these  minor  points  of  difference  that  the 
diagnosis  will  in  the  main  be  founded,  but  rather  upon  the  method 
of  evolution,  the  presence  or  absence  of  other  more  characteristic 
lesions,  the  previous  history,  careful  physical  examination  of  the 
patient,  and  the  family  history. 

The  gummatous  syphilide  when  it  appears  as  a  diffuse  eruption 
commonly  undergoes  rapid  degeneration,  presenting  much  the  appear- 
ance of  furunculosis. 

Onychia  of  a  dry  and  ulcerating  form,  and  aloj^ecia.,  are  observed 
in  connection  with  the  skin-lesions  of  hereditary  syphihs. 


HEEEDITAKY  SYPHILIS.  981 

The  lesions  of  the  mucous  membrane  correspond  in  type 
with  those  observed  upon  the  skin ;  thus,  when  pemphigus  is  noted, 
large  or  small  raw  surfaces  will  be  found  upon  the  mucous  lining 
of  the  throat  and  tongue ;  when  papular  and  papulo-pustular  erup- 
tions develop  on  the  body,  typical  mucous  patches  will  be  found  in  the 
mouth, — that  is,  superficially  ulcerated  infiltrations  covered  with  a 
grayish  necrotic  membrane. 

Not  only  the  mucous  membrane  of  the  mouth  and  pharnyx  but 
also  that  of  the  nose,  ear,  and  larynx  is  liable  to  inflammation.  In- 
deed, syphilitic  coryza  is  one  of  the  most  characteristic  and  at  the 
same  time  one  of  the  most  important  of  the  early  symptoms  of  syphi- 
hs,  since  by  its  interference  with  respiration  it  materially  hinders  the 
proper  nutrition  and  development  of  the  child.  This  condition  of  the 
nasal  mucous  membrane  is  shown  by  a  thin,  watery,  irritating  dis- 
charge, which  dries  in  crusts  about  the  nasal  orifice ;  beneath  these 
crusts  are  found  excoriations  and  ulcers.  The  catarrhal  swelling  of 
the  mucous  membrane  and  the  crusting  produce  so  much  narrowing 
of  the  air-way  that  respiration  is  difficult  and  noisy,  the  latter  symp- 
tom giving  the  popular  name  "  snuffles"  to  the  afi'ection.  Mucous 
patches,  erosions,  and  ulcers  form  on  the  lips,  particularly  at  the 
angles  of  the  mouth,  and  on  the  tongue,  the  gums,  the  palate,  and  the 
pharynx.  Caries  and  necrosis  of  the  palate  and  of  the  nasal  bones 
frequently  complicate  these  ulcerations  (syphilitic  ozsena). 

The  larynx  is  commonly  affected,  showing  the  infiltrations,  ero- 
sions, and  ulcerations  noted  on  other  mucous  surfaces,  and  causing 
the  characteristic  hoarse  voice.  Exceptionally  infiltration  narrows 
the  air-passage  to  the  point  of  producing  marked  dyspnoea,  or  even 
death. 

Later  in  the  course  of  the  disease — i.e.,  after  some  years  or  about 
the  time  of  puberty — typical  tertiary  manifestations  may  appear. 
These  are  similar  to  those  observed  in  the  adult.  They  are  character- 
ized by  deep  infiltrations,  which  exhibit  a  tendency  to  break  down, 
forming  ulcers,  which  are  accompanied  by  few  subjective  symptoms. 
Their  seat  of  predilection  is  the  soft  palate,  but  they  are  often  found  on 
the  posterior  pharyngeal  wall,  the  anterior  half-arches,  and  the  hard 
palate.  The  mucous  membrane  of  the  nose  is  also  affected,  and  the 
ulceration  is  extremely  likely  to  extend  to  the  underlying  bone,  pro- 
ducing great  deformity  or  even  complete  destruction  of  the  facial  por- 
tion of  this  organ.  The  hard  palate  and  the  nasal  septum  are  usually 
perforated. 

Lupus  rarely  attacks  either  the  mucous  membrane  or  the  bones 
of  the  nasal  passages,  being  rather  sharply  confined  to  the  regions, 


982  GENITO-UKINAEY   DISEASES  AND  SYPHILIS. 

of  the  anterior  nares.     In   these   respects  it  differs   markedly  from 
syphilis. 

When  tertiary  infiltrations  attack  the  larynx,  destruction  of  car- 
tilages may  ensue,  with  deforming  and  crippling  contractures,  or  the 
bronchi  may  be  invaded,  an  obstinate  form  of  bronchitis  resulting. 
Spasm  or  oedema  of  the  glottis  may  cause  sudden  death. 

HEREDITARY  SYPHILIS  AFFECTING  THE  EYE. 
Marginal  blepharitis  is  sometimes  encountered  as  a  result  of 
hereditary  syphilis,  appearing  in  the  form  of  small  irregular  ulcers, 
usually  near  the  corners.  The  treatment  is  cleansing  and  constitu- 
tional, together  with  the  usual  applications,  particularly  the  ointment 
of  calomel. 

The  lachrymal  apparatus  is  sometimes  involved  from  extension  of 
inflammation  dependent  on  caries  of  the  neighboring  bones. 

Interstitial  keratitis  is  the  most  characteristic  eye-lesion  of 
hereditary  syphilis.  This  commonly  begins  as  a  slight  diffuse  hazi- 
ness, situated  in  the  cornea  itself,  not  far  from  the  centre,  and  at  first 
affecting  but  one  eye  ;  usually  the  other  eye  is  affected,  but  often  not 
for  weeks  or  months.  The  cloudy  deposits  lie  in  the  cornea,  and  not 
on  its  surface,  and  first  appear  as  diffuse  spots ;  these  later  become 
confluent  until  the  whole  cornea  is  opaque,  a  bare  perception  of  light 
remaining.  There  are  usually  photophobia  and  slight  ciliary  injec- 
tion. The  disease  lasts  for  a  varying  period  of  time,  weeks  or  months  ; 
then  the  cornea  first  involved  begins  to  clear ;  the  other  cornea  fol- 
lows a  similar  course  in  time.  In  most  instances  there  remains  a 
slight  permanent  haziness,  though  vision  is  good.  In  severe  cases  the 
whole  cornea  becomes  congested,  blood-vessels  developing  in  its  sub- 
stance. Cyclitis  and  retinitis  are  often  associated  with  the  corneal 
lesions,  and  in  bad  cases  there  may  be  secondary  glaucoma  and  even 
shrinkage  of  the  eyeball. 

Interstitial  keratitis  is  rarely  noticed  in  early  infancy,  but  appears 
usually  between  the  eighth  and  the  fifteenth  year,  and  in  children 
presenting  the  typical  physiognomy  of  hereditary  syphilis. 

Diagnosis. — This  is  in  general  easy  to  make.  The  ground-glass 
appearance  in  the  early  stages,  and  the  dull  pink  or  salmon  color  if  the 
vascular  stage  is  reached,  are  characteristic.  In  syphilitic  keratitis  the 
vessels  are  deep  and  closely  interwoven,  producing  almost  the  effect 
of  an  ecchymosis.  Moreover,  in  syphilis  the  disease  is  symmetrical, 
there  is  a  tendency  to  spontaneous  cure,  ulceration  hardly  ever  oc- 
curs, and  there  is  but  slight  ciliary  congestion.  The  grooves  left  by 
the  new-formed  corneal  vessels  are  permanent,  and  their  discovery  by 


HEEEDITARY  SYPHILIS.  983 

a  magnifying  glass  long  after  other  traces  of  keratitis  have  disappeared 
will  often  throw  light  on  an  obscure  case. 

The  chief  diagnostic  point,  however,  is  the  association  of  this  form 
of  keratitis  with  other  lesions  of  syphilis. 

Iritis  appears  before  the  end  of  the  first  six  months.  It  is  later 
than  the  syphilodermata  and  of  rarer  occurrence,  but  it  is  extremely 
important,  since,  if  overlooked,  it  may  result  in  permanent  impairment 
of  the  vision.  When  recognized  it  constitutes  an  almost  pathogno- 
inonic  sign  of  syphilis. 

The  diagnosis  is  readily  made  when  attention  is  called  to  the  eye, 
but  the  affection  may  be  overlooked,  since  there  are  few  subjective 
symptoms. 

When  the  disease  is  fairly  developed  the  pupil  is  irregular,  espe- 
cially under  atropine ;  the  iris  is  streaked  mth  lymph,  dull,  swollen, 
and  discolored.  On  very  careful  inspection  a  faint  pink  zone  of  con- 
gestion may  be  seen  in  the  sclerotic,  though  this  is  often  wanting. 

The  prognosis  is  generally  good ;  even  when  the  pupil  has  been 
occluded,  vigorous  treatment  will  cause  absorption  of  the  plastic  ex- 
udate. 

The  treatment  consists  in  the  administration  of  mercury ;  it  is  often 
useful  to  give  it  in  combination  with  tonics.  When  the  disease  occurs 
during  intra-uterine  Kfe,  the  infiltration  is  liable  to  extend  to  the  lens, 
rendering  it  opaque ;  the  same  result  often  follows  when  the  disease 
develops  after  birth  and  is  not  recognized.  In  this  form  of  lens 
opacity  the  operation  for  cataract  promises  little  good. 

Optic  neuritis,  retinitis,  and  choroiditis  are  occasionally  observed 
in  the  course  of  hereditary  syphilis. 

HEREDITARY   SYPHILIS   AFFECTING  THE   EAR. 

Extension  of  inflammation  from  the  throat  and  blocking  of  the 
Eustachian  tube  may  cause  chronic  middle-ear  disease,  with  conse- 
quent deafness. 

The  characteristic  syphilitic  otitis  media  is  that  which  develops 
painlessly,  usually  within  a  few  weeks  or  a  few  months  of  birth,  and 
gives  rise  to  no  symptoms  except  a  purulent  discharge,  thus  differing 
markedly  from  the  ordinary  suppurative  otitis  media,  which  is  not 
uncommon  in  infancy  and  childhood.  This  syphilitic  otitis  yields 
promptly  and  completely  to  specific  treatment.  If  neglected  it  be- 
comes chronic,  producing  irremediable  changes,  which  result  in  partial 
deafness,  suppuration  of  the  mastoid  cells,  and  bone-involvement. 

Deafness  is  characterized  by  Hutchinson  as  one  of  the  cardinal 
symptoms  of  hereditary  syphilis.     It  is  due  to  labyrinthine  changes, 


984  GENITO-URINAET   DISEASES   AND   SYPHILIS. 

usually  affecting  both  ears.  These  changes  in  the  case  of  an  infant 
are  unaccompanied  by  subjective  symptoms,  but  result  in  deaf-mutism. 
When  the  labyrinth  is  attacked  later,  at  about  the  time  of  puberty, 
for  instance,  there  may  be  as  a  premonitory  sign  painless  tinnitus. 
Deafness  develops  rapidly,  is  complete,  and  is  apparently  causeless. 
Treatment  is  often  unavailing. 

HEREDITARY   SYPHILIS   AFFECTING  THE   TEETH. 

The  first  teeth  exhibit  malformations  and  imperfections  which  are 
by  no  means  characteristic  of  syphilis,  but  which  may  be  referred  to 
any  inflammation  of  the  gums  sufficiently  severe  to  interfere  with  the 
nutrition  of  the  tooth-sacs.  Thus,  the  teeth  are  often  deficient  in 
enamel,  or  this  coating  is  unevenly  distributed,  or  is  opaque  and 
chalky,  or  the  dentine  is  soft  and  friable,  or  the  teeth  are  incongru- 
ous in  size  individually  and  relatively,  and  decay  readily. 

The  permanent  teeth  may  exhibit  the  same  perversions  of  growth 
and  nutrition  as  a  result  of  stomatitis,  whether  this  inflammation  be 
produced  by  mercury,  by  gastro-intestinal  derangements,  or  by  local 
irritation.  Mercurial  teeth,  for  example,  are  irregularly  outlined,  hori- 
zontally seamed,  honey-combed,  scraggy,  malformed,  of  an  unhealthy, 
dirty  yellow  color,  separated  too  widely,  and  deficient  in  enamel. 

Fournier  has  written  as  follows  concerning  the  influence  of  hered- 
itary syphilis  on  the  dental  organs :  The  transmitted  taint  shows 
itself  on  the  dental  system  in  two  series  of  manifestations,  of  very 
unequal  diagnostic  value :  first,  by  retardation  of  evolution ;  second, 
by  arrest  of  growth  and  modifications  of  structure. 

Retardation  of  Evolution. — This  generally  applies  to  the  entire 
first  denture.  In  some  cases  it  is  limited  to  one  group  of  teeth, — the 
incisors,  for  example.  A  similar  retardation  sometimes  is  noted  in 
the  eruption  of  the  permanent  teeth.  This  is  but  a  locaKzed  expres- 
sion of  the  general  lack  of  development  characteristic  of  hereditary 
syphilis. 

Arrest  of  Growth  and  Modifications  of  Structure. — Perversions 
of  growth  may  be  classified  under  dental  erosions,  microdontism, 
dental  amorphism,  and  vulnerability.  Some  rarer  peculiarities,  such 
as  irregularity  of  alignment  and  anomalies  of  reciprocal  arrangement, 
are  not  included  under  any  of  the  above  headings. 

The  term  syphilitic  tooth  implies  a  congenital  dental  malforma- 
tion, a  deficiency  of  development  stamped  by  syphilis  on  the  tooth 
yet  unformed  during  the  period  of  its  intrafollicular  evolution.  The 
first  dentition  is  not  so  often  influenced  as  the  second.  The  dental 
malformations  are  commonly  multiple  and  symmetrical, — that  is,  sey- 


HEREDITAKY   SYPHILIS.  9S5 

eral  teeth  are  affected,  and  usually  corresponding  teeth  show  similar 
lesions. 

Dental  Erosion. — This  malformation  may  implicate  any  portion  of 
the  surface  or  borders  of  the  tooth.  Its  common  manifestation  on 
the  front  of  the  tooth  is  a  cupping,  comparable  to  the  slight  depres- 
sion which  would  be  left  by  the  point  or  the  head  of  a  pin  in  soft 
wax.  These  cuppings  show  a  dark  tint,  grayish,  brownish,  or  almost 
black,  and  in  the  deeper  depressions  enamel  is  entirely  wanting. 
Erosions  in  this  form  are  most  common  on  the  incisors,  and  notably 
on  the  superior  centrals,  and  are  often  arranged  in  one  or  more 
horizontal  rows. 

Faceted  erosion  is  not  so  common.  It  usually  involves  the  cen- 
tral incisors,  and  shows  as  an  irregularity  such  as  would  be  pro- 
duced by  a  file.  It  is  extremely  superficial,  and  can  often  be 
detected  only  by  examining  the  previously  dried  tooth  under  a  mag- 
nifying glass. 

The  furrowed  erosion  is  the  commonest  form,  and  appears  as  a 
transverse  groove,  which  may  make  the  entire  circuit  of  the  tooth,  or 
may  be  broken.  The  groove  may  be  so  shallow  as  to  form  a  scarcely 
perceptible  streak,  or  it  may  be  deep,  as  though  filed,  producing  an 
unsightly  deformity,  since  it  soon  acquires  a  dark  tint.  These  furrows 
are  always  horizontal  and  usually  single.  Sometimes  two  or  three 
are  noticed  on  the  same  tooth,  occupying  the  portion  of  the  crown 
nearest  the  free  edge.  In  such  teeth  the  free  extremity  is  generally 
worn  thin,  partly  or  totally  deprived  of  enamel,  rough,  uneven,  ir- 
regular, brownish,  and  rapidly  wears  away.  These  grooved  erosions 
are  most  frequent  on  the  incisors. 

Surface  erosion  is  rare.  It  represents  simply  an  exaggerated  form 
of  the  grooved  erosion,  covering  a  large  surface  of  the  crown  and  pre- 
senting a  wide,  unequal,  and  rough  zone  filled  with  alternate  points 
and  sinuosities  and  of  a  dirty  yellow  or  blackish  color.  In  its  most 
pronounced  form  it  appears  as  a  completely  disorganized  mass,  un- 
recognizable  as  a  tooth. 

The  malformations  affecting  the  cutting  or  grinding  surfaces  of 
the  teeth  present  themselves  under  different  forms,  according  to  the 
class  of  teeth  they  affect. 

The  first  molar  is  the  only  one  among  the  grinders  upon  which 
the  influeuce  of  hereditary  syphilis  shows  itself.  The  body  of  the 
tooth  for  two-thirds  or  three-fourths  of  its  height  is  normal ;  its  upper 
surface  is  atrophied,  suggesting  a  stump  of  dentine  emerging  from  a 
normal  crown.  The  masticating  surface  is  rough  and  of  a  dirty- 
yellow  or  brown  tint,  and  wears  away,  producing  a  flat  surface  with 


986 


GENITO-UEINARY   DISEASES  AND   SYPHILIS. 


a  yellowish  centre  and  a  peripheral  border  of  white  enamel.     This 
short,  flat  tooth  has  a  diagnostic  significance  of  high  value. 

Upon  the  cuspids  erosion  of  the  free  edge  may  appear  as  a  simple 
notch,  similar  to  a  cut  made  in  a  piece  of  wood  by  two  convergent 
strokes  of  a  knife,  or  as  a  true  atrophy,  producing  the  appearance  of  a 
slender  conical  stump  grafted  in  a  cylinder. 

Erosions  of  the  cutting  edge  of  the  incisors  are  more  numerous. 
There  may  be  an  angular  notch,  serration,  atrophic  thinning,  with 
antero-posterior  flattening,  or  general  atrophy,  the  tooth  presenting  a 
normal  base,  from  which  emerges  a  small,  rough,  dirty-gray  stump 
with  an  uneven  surface. 

Finally,  there  is  the  crescent-shaped  erosion  characterized  by  a 
semilunar  notch,  constituting  the  Hutchinson  tooth.  The  important 
peculiarity  of  this  last  erosion  is  the  semicircular  cut  in  the  free  edge 
of  the  tooth.  The  superior  central  incisors  are  the  teeth  which  ex- 
hibit this  characteristic  crescentic  notch.  It  is  impossible  to  mistake 
it  or  seriously  to  consider  it  in  connection  with  any  other  affection 
of  the  dental  organs.  The  crescentic  notch  is  the  essential  charac- 
teristic of  the  Hutchinson  tooth,  but  is  not  the  exclusive  one.  The 
notch  is  nearly  always  bevelled  at  the  expense  of  the  anterior  edge  of 
the  tooth ;  in  other  words,  the  anterior  border  of  the  crescentic  arch 
is  cut  obliciuely  from  above  downward  and  from  before  backward. 
The  typical  Hutchinson's  tooth  is  also  marked  by  its  rounded  angles, 
the  lateral  and  inferior  borders  merging  by  a  curved  line  ;  it  is  much 
reduced  in  length;  sometimes  it  is  narrowed.  Finally,  the  upper 
central  incisors  having  the  Hutchinson  notch  often  deviate  from  nor- 
mahty  in  direction,  and  their  axes  in  place  of  being  parallel  are  ob- 
Hquely  convergent. 

A  perfect  type  of  this  tooth  is  best  observed  in  youth.  It  does  not 
protrude  from  the  gum  with  a  clearly  cut  notch,  appearing  first  with 
this  notch  either  partially  or  completely  filled  by  smah  or  apparently 
atrophied  vegetations  of  the  dental  tissue.  Deprived  of  enamel,  these 
vegetations  are  rapidly  destroyed,  leaving  in  their  place  the  smooth 
crescentic  notch,  the  depth  of  which  progressively  diminishes  with 
use.  At  twenty-five  years  the  vault  becomes  nearly  flat,  but  even 
then  there  remains  the  bevel  of  its  anterior  edge.  Later  with  the 
wearing  of  the  tooth  the  bevel  disappears,  so  that  beyond  the  age 
of  thirty  years  Hutchinson's  teeth  are  not  to  be  found.  This  dental 
malformation  commonly  affects  the  two  teeth  symmetrically,  often 
exclusively.  Sometimes  it  is  observed  in  the  upper  lateral  incisors, 
the  inferior  incisors,  or  even  the  cuspids. 

In  the  second  dentition  dental  erosions  are  met  with  in  the  fol- 


HEKEDITAKY   SYPHILIS.  987 

lowing  order  of  frequency :  first,  on  the  first  molars,  particularly  those 
of  the  lower  jaw  ;  second,  on  the  incisors  ;  third,  on  the  cuspids.  The 
bicuspids  and  second  and  third  molars  are  almost  invariably  exempt 
from  these  erosions. 

Erosions  are  usually  multiple  and  nearly  always  symmetrical. 
Those  of  corresponding  teeth  maintain  the  same  level  on  the  crown. 

As  to  the  semeiological  value  of  dental  erosions,  the  punctate  and 
cup-like  lesions  of  the  crown  and  the  saw-like  erosions  of  the  free 
edge  have  but  little  value  as  evidence  of  specific  heredity.  Furrowed 
erosions  are  more  characteristic,  but  are  also  caused  by  other  condi- 
tions than  hereditary  syphilis. 

Atrophy  of  the  dental  cusp,  notably  that  affecting  the  first  molar, 
and  constituting  the  short,  flat  tooth,  has  a  more  precise  meaning, 
because  this  is  a  favorite  form  of  the  malformation  when  caused  by 
syphilis. 

The  best  form — one  which  can  be  given  as  an  almost  certain  evi- 
dence of  syphilitic  heredity — is  the  semilunar  notch  of  the  free  border 
of  the  central  superior  incisors.  This  special  form  of  erosion  is  a 
diagnostic  feature  of  incontestable  value. 

Microdontism,  the  term  implying  an  unusual  smallness  of  the  teeth, 
sometimes  amounting  to  actual  dwarfing,  never  involves  the  entire 
denture.  The  superior  and  inferior  lateral  incisors  are  the  teeth  most 
frequently  affected. 

Amorphism  indicates  that  a  tooth  has  assumed  some  shape  other 
than  its  physiological  one.  This  growth-perversion  is  almost  as  fre- 
quent as  erosion.  The  teeth  may  present  simply  deviation  of  normal 
type,  exhibiting  characteristics  of  a  class  to  which  they  do  not  belong, 
or  they  may  be  so  malformed  that  they  become  true  monstrosities, 
forming  shapeless  masses. 

Typical  erosion,  microdontism,  and  the  lesions  of  amorphism  may 
be  associated.  The  tooth  affected  by  syphilis  is  always  vulnerable 
and  subject  to  secondary  deteriorations.  Caries  develops  at  an  early 
age.  The  first  molars  are  the  teeth  most  exposed  to  these  degenera- 
tions.    They  are  often  destroyed  in  youth. 

Among  the  least  common  lesions  of  syphilis,  Foamier  describes  a 
white  linear  stripe  running  horizontally  over  the  crown  of  the  tooth 
from  one  lateral  border  to  the  other,  usually  placed  on  the  superior 
central  incisors,  and  affecting  both  alike.  Irregularities  of  implanta- 
tion are  also  frequent,  the  teeth  being  often  separated  from  one 
another  by  large  empty  spaces. 

It  may  be  considered  as  well  established,  then,  that  when  the  two 
upper  central  incisors  are  stunted,  abnormally  narrow  at  the  cutting 


988 


GENITO-URINARY  DISEASES  AND   SYPHILIS. 


edge,  crescentically  rounded  with  the  convexity  upward,  and  the  sur- 
face inclined  upward  and  forward  instead  of  backward,  as  in  normal 
teeth,  widely  separated,  but  converging  at  their  lower  edges,  they  are 
pathognomonic  of  hereditary  syphilis.  Other  lesions  of  the  enamel  or 
dental  substance,  possibly  with  the  exception  of  the  incomplete  devel- 
opment of  the  first  molar  described  by  Fournier,  although  frequently 
caused  by  hereditary  syphilis,  may  be  due  to  other  dyscrasiae,  and  in 
themselves  are  not  characteristic. 

HEREDITARY  SYPHILIS  AFFECTING  THE  BONES  AND  JOINTS. 
The  bones  are  much  more  frequently  involved  in  hereditary 
syphihs  than  in  the  acquired  disease.  They  are  usually  attacked  be- 
tween the  fifth  and  the  nineteenth  year  of  age  (Fournier),  though 
they  may  be  involved  at  any  stage  of  the  disease.  As  hereditary 
syphilis  develops  in  young  children  it  attacks  by  preference  the  bones 
of  the  cranium  and  nose  and  the  long  bones,  particularly  the  tibia. 
Later  in  life  the  skull  is  affected  in  a  smaller  percentage  of  cases,  the 
tibia  still  exhibiting  lesions  most  frequently. 

As  in  acquired  syphihs,  the  essential  lesions  are  those  of  periostitis, 
ostitis,  osteomyehtis,  and  gummatous  infiltration.  They  are  usually 
formative  rather  than  destructive  in  type. 

Osteochondritis  occurring  at  the  diaphyso-epiphyseal  junction  of 
the  long  bones  is  pathognomonic  of  syphilis.  It  is  characterized  by 
a  marked  vddening  of  the  cartilaginous  plate  between  the  epiphyses 
and  the  diaphyses,  by  irregular  growth  of  the  bone  layer  just  beneath 
the  cartilaginous  plate,  and  by  softening  at  this  point  of  juncture, 
allowing  epiphyseal  separation.  Microscopically  there  is  found  a 
proliferation  of  cartilage  ceUs  and  an  arrest  in  the  transformation  of 
these  cells  to  bone. 

The  symptoms  of  this  form  of  osteochondritis  are  as  follows : 
The  bones  most  frequently  attacked  are  the  humerus,  radius,  ulna, 
tibia,  and  femur,  but  the  ribs,  sternum,  and  bones  of  the  metatarsus 
and  metacarpus  are  also  often  involved.  The  more  pronounced  the 
syphilis  of  the  parents  or  the  nearer  the  date  of  conception  to  the 
time  at  which  their  infection  occurred,  the  more  probable  is  it  that 
several  bones  will  be  affected  and  the  more  unfavorable  is  the  prog- 
nosis as  respects  the  life  of  the  child. 

There  is  a  swelling  at  the  diaphyso-epiphyseal  junction  of  one  of 
the  long  bones,  appearing  in  the  form  of  a  smooth  ring  or  collar,  which 
more  or  less  completely  surrounds  the  bone.  In  the  course  of  some 
weeks,  as  the  swelling  becomes  more  pronounced,  there  may  be  a 
moderate, amount  of  synovitis  present,  particularly  when  the  disease 


HEREDITAKY  SYPHILIS.  989 

is  placed  about  the  knee  or  the  elbow-joint.  At  this  stage — i.e.,  that 
of  overgrowth  and  infiltration — the  lesion  is  readily  influenced  by 
specific  treatment  and  well-regulated  pressure. 

If  softening  and  suppuration  take  place  there  is  complete  separa- 
tion of  the  epiphyses  and  diaphyses,  shown  by  preternatural  mobility, 
crepitus,  and  syphilitic  pseudo-paralysis,  the  affected  hmbs  losing  all 
power.  The  pus  may  break  into  the  joint-cavity,  destroying  the  car- 
tilage, or  may  burrow  into  surrounding  soft  parts.  The  lesions  of 
osteochondritis  are  usually  multiple. 

The  bones  of  the  skull,  particularly  the  parietal,  frontal,  and  oc- 
cipital, are  affected  by  formative  lesions. 

Microcephalus,  possibly  due  to  premature  ossification  of  sutures 
or  lack  of  development  of  the  cerebrum,  hydrocephalus,  or  lack  of 
symmetry  in  the  shape  of  the  cranium,  may  be  noted. 

Lack  of  symmetry  is  especially  frequent  and  characteristic.  Four- 
nier  has  described  a  number  of  types  :  thus,  there  are  the  broad,  high, 
bulging  forehead;  the  bossed  forehead,  the  projections  on  either  side 
corresponding  to  the  frontal  eminences,  with  an  apparent  depression 
in  the  middle  ;  and  the  keeled  or  chicken-breasted  forehead,  with  a 
median  projection.  The  asymmetry  in  these  cases  is  due  to  formative 
osteoperiostitis  of  the  frontal  bones.  When  the  parietal  bones  are 
affected  there  results  the  natiform  skull,  presenting  apparent  broaden- 
ing of  the  cranium,  with  a  central  depression,  suggesting  the  shape  of 
the  nates.  When  the  nodes  or  exostoses  are  found  in  the  regions  of 
the  frontal  and  parietal  eminences  they  are  often  called  "  Parrot's 
nodes." 

The  degenerative  lesions  of  the  skull  are  characterized  by  tumor- 
formation,  softening,  breaking  down,  and  extensive  ulceration  and 
destruction  of  bone-tissue.  After  the  first  few  years  of  life  the 
cranium  is  rarely  affected;  the  bones  of  the  nose,  however,  are  not 
spared. 

The  bones  of  the  nose  and  face  are  rarely  affected  in  early  in- 
fancy;  when  they  are  involved  later  in  life,  it  is  usually  from  an  ex- 
tension of  disease,  which  primarily  attacks  overlying  soft  parts. 

With  regard  to  the  long  bones,  the  tibia  is  the  telltale  above  all 
others.  Swellings  and  nodes  are  the  rule,  deforming  the  diaphysis, 
either  flattening  out  the  crest  or  by  bony  deposits  curving  it  until  it 
has  the  shape  of  a  sabre.  This  sabre-shaped  tibia  is  a  most  important 
evidence  of  hereditary  syphilis.  The  chicken-breasted  thorax  is  also 
frequently  observed. 

Exceptionally  syphilis  manifests  itself  in  the  form  of  a  rarefying 
ostitis,  predisposing  to  fracture. 


990 


GENITO-UEINAKT   DISEASES   AND   SYPHILIS. 


Diagnosis. — The  bone-lesions  of  hereditary  exostoses  can  be  recog- 
nized by  the  fact  that  they  are  stationary,  appear  later  than  those  of 
syphihs  and  are  of  larger  size,  are  accompanied  by  no  syphilitic 
history  or  symptoms,  and  resist  specific  treatment.  Syphilitic  osteo- 
chondritis, followed  by  separation  of  the  epiphyses  and  complicated  by 
suppuration  and  sinuses,  may  be  mistaken  for  a  similar  condition  due 
to  non-specific  inflammations ;  the  latter,  however,  occur  much  later 
in  hfe,  are  attended  wdth  more  acute  inflammatory  symptoms,  and 
are  not  accompanied  by  other  symptoms  or  traces  of  syphihs. 

The  characteristics  of  the  specific  and  of  the  non-specific  osteo- 
periostitis may  be  thus  contrasted  : 


Syphilitic  Osteoperiostitis. 

Occurs  in  infants  under  three  months 
of  age. 

History  of  syphilis  in  child  and  its 
parents. 

Implication  of  other  bones. 

Coincident  with  the  development  of  the 
shaft  of  the  bone. 

Other  lesions  of  syphilis, — nodes,  skin- 
eruptions,  etc. 

All  the  local  symptoms  comparatively 
mild. 

Disease  sharply  localized. 

Lymphatics  of  limb  unaffected. 

Beneiicial  effect  of  specific  treatment  if 
employed  early. 


Non-Specific  Osteoperiostitis. 
Seldom,    if   ever,    occurs    in    children 

under  one  year  of  age. 
No   history   of  syphilis ;    sometimes   a 

history  of  traumatism. 
Usually  confined  to  one  bone. 
Coexists   with   the    ossification   of   the 

epiphyses. 
No  such  symptoms. 

Pain,  redness,  and  swelling  very  marked. 

Involves  neighboring  parts. 
Lymphangitis  sometimes  present. 
No  such  effect. 


Rickets  so  frequently  complicates  syphilis  that  the  latter  is  often 
regarded  as  the  essential  etiological  factor  in  the  development  of  this 
disease  of  the  bones.  This,  however,  will  not  stand  the  test  of  clinical 
investigation.  As  is  the  case  with  tuberculosis,  which  often  runs  its 
course  in  conjunction  with  hereditary  syphilis,. rickets  is  a  distinct 
disease.  The  contrasted  characteristics  of  the  two  affections  may  be 
thus  tabulated : 


Osseous  Lesions  due  to  Inherited  Syphilis. 

The  swellings,  particularly  those  of  the 
long  bones,  show  themselves  at  or 
soon  after  birth. 

A  history  of  syphilis  or  evidence  of  ex- 
isting syphilis  in  one  or  both  parents. 

Preceded  or  accompanied  by  snuffles, 
coryza,  and  cutaneous  and  mucous 
lesions. 


Riclcets. 
Rarely  appear  before  six  months,  gen- 
erally still  later. 

No  such  history  necessarily. 

No  such  prodromata. 


HEKEDITAKY   SYPHILIS. 


991 


Osseous  Lesions  due  to  Inherited  Syphilis. 

Prodromata  recognized  as  characteristic 
of  rickets  do  not  precede  the  bone- 
disease. 

Cachexia  absent  or  moderate. 
Physiognomical  peculiarities  of  syphilis 

present. 
Circumscribed    tumors   on  parietal   or 

frontal  bones,  rarely  on  occiput. 
Ribs  not  markedly  affected. 
Disease    of   ribs,    when    existent,   not 

ordinarily   coincident  with    that    of 

other  bones. 
Fontanelles  close  at  usual  period. 
Other   syphilitic   symptoms    present, — 

enlargement  of  phalanges,  metatarsal 

bones,  etc. 
Often  accompanied  by  sinuses,  synovitis, 

abscesses,  cutaneous  ulcers,  etc. 
Generally  disappear  by  resolution,  with- 
out leaving  any  permanent  change. 

Mortality  among  children  in  whom 
many  bones  are  involved  is  very 
great. 

Specific  treatment  useful. 

In  the  first  stage  there  is  exuberant  cal- 
cification of  the  ossifying  cartilage, 
causing  necrosis  of  the  new-formed 
tissue  and  a  consecutive  inflammation, 
which  terminates  in  the  separation  of 
the  epiphyses.^ 


Rickets. 

Pallor,  restlessness,  sweating,  nausea, 
diarrhoea,  etc.,  constitute  a  combina- 
tion of  symptoms  vvhicii  often  precede 
the  bone-disease. 

Cachexia  marked. 

Not  present  as  a  group. 

Cranial  bones  thickened  in  spots,  usu- 
ally upon  the  occiput. 
All  or  nearly  all  involved. 
Nearly  always  so. 


Closure  delayed. 
Syphilitic  symptoms  absent. 


Little  external  or  surrounding  involve- 
ment. 

Usually  leaves  some  bending  of  shaft 
and  distortion  of  the  neighboring 
joint. 

Much  less. 


Of  no  benefit. 

This  is  less  marked.  There  is  often 
formed  instead  a  soft  and  non-calci- 
fied osteoid  tissue. 


Syphilitic  dactylitis  commonly  develops  in  infants.  The  infil- 
tration may  affect  the  subcutaneous  and  periarticular  tissue,  or  the 
disease  may  begin  in  the  bone  or  periosteum  and  later  involve  the 
fibrous  structures  about  the  joints. 

The  deep  form  is  a  specific  osteomyelitis,  and  often  destroys  the 
bone  and  the  articulation.  The  articular  ends  of  the  first  phalanges 
are  usually  affected. 

Symptoms. — Syphilitic  dactylitis  is  characterized  by  the  appearance 
of  an  ill-defmed,  fusiform,  purphsh  swelling,  which  softens,  breaks 
down,  and  discharges.     The  lesions  are  often  multiple,  painless,  affect 

^  This  table  is  founded  on  one  published  in  the  translation  of  Cornil  on 
Syphilis,  by  Drs.  Simes  and  White,  and  is  compiled  chiefly  from  the  excellent  work 
of  Dr.  Taylor  on  this  subject. 


992  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

the  fingers  rather  than  the  toes,  and  in  the  more  serious  forms  lead  to 
destruction  of  tissue  and  marked  interference  with  growth. 

Diagnosis. — Specific  dactyhtis  must  be  differentiated  from  felon, 
from  rheumatoid  arthritis,  from  enchondroma  and  exostoses,  and  from 
tubercular  diseases. 

Felon  exhibits  the  symptoms  of  acute  inflammation,  and  is  rapid 
in  its  course.    Rheumatoid  arthritis  begins  primarily  in  the  joints,  and 

is    associated    with    other   characteristic 
■  ^  '^'  symptoms.     Enchondroma  and  exostoses 

develop  much  more  slowly,  and  are  more 
,,^,  circumscribed. 

Tubercular  dactylitis  runs  a  slower 
course,  is  rarely  symmetrical,  sometimes 
shows  the  bacilli  of  tuberculosis,  is  not 
benefited  by  specific  treatment,  and  dis- 
appears very  slowly. 

The  treatment  consists  in  the  admin- 

\  istration  of  mercury  and  the  iodides,  com- 

\  I  billed   with  curetting  or  resection  when 

\  \  abscesses  have  formed  and  dead  bone  is 

present. 

The   Joints. — Fournier   describes  a 

Syphilitic  dactylitis.  fo™  of  joint-involvemeut  which  he  terms 

arthralgia,  characterized  simply  by  pain. 

It  is  apparently  causeless,  is  irregular  in  onset,  varies  in  degree,  and 

has  a  tendency  to  become  more  severe  at  nights. 

The  lesions  of  the  joints  are  practically  the  same  as  those  of 
acquired  syphihs.  Fournier  describes  three  forms  of  arthrosis.  The 
first  presents  the  appearance  of  simple  chronic  hydrarthrosis.  Close 
examination  shows  that  the  affection  of  the  joint  masks  a  bone-lesion, 
perhaps  an  epiphysitis  or  a  periostitis. 

The  second  form  presents  the  symptoms  of  syphilitic  Avhite  swell- 
ing. There  is  a  somewhat  globular  tumefaction,  made  up  almost  en- 
tirely of  an  extensive  hyperostosis  of  the  epiphyses,  aided  by  moderate 
synovial  effusion.  There  are  no  involvement  of  the  integument,  dis- 
coloration, heat,  oedema,  or  inflammatory  symptoms.  On  palpation 
the  tumor  is  felt  to  be  of  bony  hardness.  It  is  not  sensitive  and  does 
not  occasion  pain.     Function  is  not  materially  interfered  with. 

The  third  form  presents  deforming  arthropathies  dependent  upon 
epiphyseal  malformation.  The  shape  of  the  swelling  is  irregular  and 
at  times  extraordinary.  Osteophytes  materially  interfere  with  func- 
tion, and  sometimes  occasion  complete   ankylosis.      When  they  are 


HEREDITAKY  SYPHILIS.  993 

developed  at  an  early  age  they  are  accompanied  by  muscular  atrophy 
and  arrested  development  of  the  affected  part. 

HEREDITARY  SYPHILIS  AFFECTING  THE    LYMPHATIC    GLANDS. 

The  enlargement  of  the  lymphatic  glands  is  painless,  slow,  and 
without  tendency  to  suppuration.  The  anterior  cervical  group  is  most 
commonly  affected.  The  tumors  hardly  ever  attain  large  size,  and 
remain  indefinitely  without  marked  change.  The  enlarged  glands  of 
hereditary  syphilis  are  found  in  the  regions  affected  by  tubercular 
glandular  enlargements,  and  in  the  early  stage  of  their  evolution  ex- 
hibit the  same  symptoms.  The  absence  of  ulcerative  tendency  and 
of  general  lymphatic  involvement,  the  permanency  of  the  growth,  and 
the  effect  of  specific  treatment  make  the  diagnosis  clear. 

HEREDITARY  SYPHILIS  AFFECTING  THE  NERVE-CENTRES  AND  NERVES. 

The  Brain. — The  lesions  which  attack  the  nerve-centres  may 
appear  in  the  form  of  endarteritis,  diffuse  infiltration,  or  gummata. 

When  the  brain  is  involved  the  lesions  are  usually  multiple  and 
diffuse,  and  give  rise  to  a  variety  of  symptoms. 

Paralyses  are  among  the  characteristic  symptoms.  These  may  be 
limited  or  general,  but  when  they  are  repeated,  multiple,  or  recurrent, 
and  particularly  when  they  involve  symmetrical  portions  of  the  body, 
they  suggest  syphilis.  The  three  clinical  types  recognized  in  acquired 
syphilis  are  commonly  seen  in  the  inherited  disease, — i.e., 

1.  Those  characterized  by  sudden  palsies,  due  to  the  thrombosis 
of  endarteritis. 

2.  Those  characterized  by  symptoms  of  brain-tumors,  due  to  gum- 
matous formations. 

3.  Those  characterized  by  headache  and  various  functional  or 
convulsive  disturbances,  such  as  epilepsy,  neuralgia,  or  chorea,  due  to 
periostitis  or  meningitis. 

The  following  is  a  resume  of  Fournier's  teaching.  The  lesions  of 
the  cerebrum  may  involve  the  encephalon  primarily  or  may  extend 
from  neighboring  parts.  Syphihs  is  undoubtedly  one  of  the  causes 
of  hydrocephalus.  Infiltrations  and  gummata  of  the  brain  and  its 
meninges  have  been  observed  at  birth.  If  the  child  survives  these 
lesions  they  manifest  themselves  later  by  paralysis,  paresis,  or  en- 
feebled cerebration,  shown  by  a  certain  mental  incapacity  or  slow- 
ness, or  even  by  actual  imbecility  or  idiocy.  Children  thus  afflicted 
develop  slowly,  talk  late  and  with  difficulty,  are  forgetful,  and  are 
characterized  as  backward  ;  or  they  exhibit  no  reasoning  power,  speak 
at  most  a  few  incoherent  words,  are  subject  to  fits  of  ungovernable 

63 


994  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

rage,  and  often  suffer  from  associated  defects  of  vision  and  permanent 
or  transient  muscular  incoordination,  shown  by  awkwardness,  tremors, 
weakness  of  the  legs,  staggering  gait,  etc.  These  pronounced  cases- 
are  rare,  because  lesions  sufficient  to  produce  them  are  nearly  always 
fatal  in  early  life. 

Cerebral  syphilis  manifesting  itself  -after  the  period  of  infancy  (late 
hereditary  syphilis)  may  exhibit  as  its  cardinal  symptoms — 

1.  Convulsions  epileptic  in  type, 

,2.  Cephalalgia. 

3.  Disturbed  cerebration. 

Epileptic  Symptoms. — These  may  develop  as  pure  epilepsy,  char- 
acterized by  a  succession  of  convulsive  attacks,  coming  on  suddenly 
in  the  midst  of  apparently  perfect  health,  or  by  epilepsy  associated 
with  other  symptoms,  such  as  recurrent,  intermittent  headaches, 
heaviness,  vertigo,  and  enfeebled  intellect.  As  the  disease  progresses, 
symptoms  of  cerebral  congestion  develop,  characterized  by  vertigo, 
tinnitus,  amblyopia,  loss  of  vivacity,  dulness,  inaptitude  for  talking  or 
for  work,  loss  of  memory,  enfeeblement  of  reasoning  power,  hebetude, 
paresis  or  partial  paralysis,  particularly  of  the  ocular  muscles,  and 
finally  hemiplegia.  In  this  form  of  the  disease  treatment  inaugurated 
during  the  epileptic  stage,  before  the  advent  of  other  cerebral  symp- 
toms, is  almost  certainly  curative.  When  the  disease  is  well  advanced 
and  paresis  developed,  the  prognosis  must  be  extremely  guarded. 

Cephalalgia. — The  forms  of  hereditary  syphilis  characterized  in 
the  beginning  by  cephalalgia  as  the  major,  often  the  sole,  symptom 
are  well  authenticated.  The  pain  is  general,  dull,  and  heavy  rather 
than  lancinating  and  neuralgic,  and  involves  the  whole  head.  It  is 
subject  to  nocturnal  exacerbations,  and  is  persistent.  This  latter 
quality  is  most  important  from  a  diagnostic  stand-point.  It  is  shortly 
followed  by  other  symptoms,  especially  epileptic  crises,  the  latter  ap- 
pearing in  a  few  weeks. 

Disturbed  Cerebration. — The  third  form  of  cerebral  syphilis,  char- 
acterized by  disturbance  of  the  intelligence,  usually  coexists  with  other 
cerebral  phenomena.  Occasionally  it  appears  as  the  first  and  for  a 
time  the  only  cerebral  manifestation  of  the  disease.  It  may  be  ex- 
pressed in  the  form  of  intellectual  asthenia,  the  child  losing  the  faculty 
of  attention  and  becoming  petulant,  forgetful,  easily  fatigued,  dull, 
heavy,  lethargic,  even  torpid.  After  several  weeks  or  months,  head- 
aches develop,  followed  by  symptoms  of  congestion  and  epileptic 
seizures. 

In  whatever  form  the  disease  begins,  if  unchecked  it  ends  in  dis- 
turbance of  the  intellect  and  paresis  or  paralysis.     Its  course  may  be 


HEREDITARY   SYPHILIS.  995 

rapid,  corresponding  to  the  symptomatology  of  acute  or  subacute  men- 
ingitis or  cerebral  tumors,  or  may  be  chronic,  lasting  for  several  years. 
Diagnosis. — The  diagnosis  of  cerebral  syphilis  from  tubercular 
meningitis  is  sometimes  impossible.  It  may  generally  be  founded 
upon  the  following  points  : 

1.  Cerebral  syphilis  is  not  accompanied  by  fever  ;  tubercular  men- 
ingitis exhibits  fever  in  the  initial  period,  and  in  the  course  of  the 
disease  shows  characteristic  oscillations  of  temperature. 

2.  Cerebral  syphilis  does  not  cause  sudden  changes  in  the  color  of 
the  face  from  pale  to  red,  retraction  of  the  belly,  irregularity  of  the 
pulse.  Disordered  relation  between  pulse  and  temperature  is  charac- 
teristic of  tubercular  meningitis. 

3.  The  hydrocephalic  cry,  obstinate  constipation  in  the  beginning 
of  the  attack,  vomiting,  delirium,  photophobia,  chewing,  grinding  of 
the  teeth,  and  opisthotonos  are  much  more  frequently  observed  in 
tubercular  meningitis  than  in  cerebral  syphilis. 

4.  Tubercular  meningitis  often  rapidly  and  markedly  affects  the 
general  condition,  causing  emaciation  and  the  symptoms  of  serious 
illness.     The  same  changes  are  not  so  prominent  in  cerebral  syphilis. 

The  diagnosis  of  syphilitic  epilepsy  from  epilepsy  due  to  other 
causes,  one  of  cardinal  importance  to  establish,  will  depend  upon  the 
rapid  development  of  other  cerebral  symptoms  characteristic  of  heredi- 
tary syphilis.  Thus,  disturbances  of  the  intellect  are  early  observed ; 
frequently  partial  palsy  follows  the  attacks  in  the  early  stages.  More- 
over, in  the  intervals  of  the  attack  there  are  found  symptoms  of  cere- 
bral involvement.  All  these  symptoms  develop  slowly  in  true  epilepsy. 
Finally,  epileptic  attacks  which  are  frequent  and  multiple  in  the  early 
stages,  or  which  are  partial  and  lateralized,  are  much  more  character- 
istic of  syphilis  than  of  common  epilepsy. 

It  is  apparent  that  cerebral  syphilis  has  no  individual  symptoms  of 
its  own :  hence  the  diagnosis  will  in  the  main  be  founded  upon  hered- 
itary specific  antecedents. 

The  Spinal  Cord. — Gummatous  infiltration,  as  in  acquired  syph- 
ilis, may  involve  the  membranes  or  the  cord  itself.  These  lesions 
may  be  secondary  to  bone-involvement ;  the  first  symptom  is  usually 
paralysis  of  the  legs.  When  the  seat  of  involvement  is  high  up  this 
palsy  may  involve  the  arms  also. 

The  diagnosis  will  be  founded  upon  the  history  and  the  associated 
signs  of  the  disease.  Fournier  summarizes  the  matter  by  stating  that 
certain  paraplegias  of  infancy  or  even  of  the  adult  can  originate  from 
hereditary  syphilis.  Tabes,  he  states,  may  have  the  same  etiology, 
since  it  is  so  frequently  associated  with  syphilis  of  the  adult,  and 


996  GENITO-TEIXAKY   DISEASES   AND   SYPHILIS. 

clinical  observation  of  a  limited  number  of  cases  seems  to  establish 
this  fact. 

Disseminated  sclerosis,  he  holds,  is  much  more  frequent  in  infancy 
and  youth  than  is  generally  believed.  It  offers  practically  the  same 
symptomatology^  as  in  the  adult,  and  among  the  etiological  factors 
syphilis  must  be  admitted  as  an  important  one  in  certain  cases.  Four- 
nier  has  observed  as  the  result  of  hereditary  syphilis  isolated  palsy 
of  the  oculo-motor  nerve,  and  quotes  Nettleship's  case  of  paralysis  of 
the  common  oculo-motor,  the  abducens,  and  the  trigeminal  nerve. 
Ormerod  is  also  quoted  as  observing  a  case  of  palsy  of  the  median 
nerve  with  gummatous  swelling  of  the  trunk. 

HEREDITARY  SYPHILIS  AFFECTING  THE  VISCERA. 

The  Lungs. — The  lungs  are  more  frequently  attacked  by  hered- 
itary than  by  acquired  syphilis.  The  disease  may  appear  as  gum- 
mata  or  as  a  diffuse  infiltration. 

Gummata  of  the  lungs,  the  common  form  of  involvement,  affect 
chiefly  the  middle  and  lower  posterior  portions,  appearing  as  miliary, 
pea-sized,  sometimes  cherry-sized,  nodules. 

Diffuse  infiltration,  the  so-called  white  pneumonia,  is  often  asso- 
ciated with  gummata.  It  may  involve  several  lobules  or  lobes. 
The  portion  of  the  lung  affected  is  dense  and  of  a  lighter  color  than 
normal,  due  in  part  to  the  ansemia  incident  to  perivascular  connective- 
tissue  growth  with  thickening  of  the  vessel-coats.  The  alveoli  are 
filled  with  epithelial  cells  undergoing  fatty  degeneration.  Diffuse  in- 
filtration, if  extensive,  is  necessarily  fatal  at  birth.  Apparently  chil- 
dren suffering  from  this  lesion,  even  though  it  be  hmited,  live  but  a 
few  days  or  weeks. 

Diagnosis. — The  diagnosis  of  specific  lung-involvement  in  syphilitic 
infants  cannot  be  made.  Many  such  infants  perish  of  broncho-pneu- 
monia ;  this,  however,  is  an  expression  of  vulnerability  rather  than 
of  the  localization  of  a  specific  lesion. 

The  Liver. — Examinations  of  children  still-born  because  of 
hereditary  syphilis  show  that  lesions  of  the  liver  are  most  constant. 
The  liver  may  be  the  only  viscus  involved.  The  usual  form  is  a  dif- 
fuse interstitial  hepatitis,  though  true  gummatous  hepatitis  may  be 
observed  at  birth.  There  is  marked  enlargement,  the  liver,  always 
disproportionately  large  in  young  children,  being  sometimes  three  or 
four  tunes  its  normal  size. 

The  only  symptom  which  excites  attention  is  the  enlargement. 
Exceptionally,  from  obliteration  of  the  bile-ducts,  jaundice  develops. 

The  Spleen. — The  spleen  is  enlarged  at  birth  or  shortlv  after  in 


HEEEDITARY   SYPHILIS.  997 

about  twenty  per  cent,  of  the  cases  of  hereditary  syphilis.  The  lesion 
usually  appears  in  the  form  of  diffuse  interstitial  splenitis,  and  may 
form  a  tumor  three  times  the  size  of  the  normal  organ.  The  increase 
in  size  seems  to  be  mainly  due  to  a  simple  hypereemia.  Enlargement 
of  the  spleen  is  a  valuable  aid  to  diagnosis.  Moreover,  the  amount 
and  persistence  of  the  swelling  give  an  approximate  indication  of  the 
severity  of  the  case.  Liver-enlargement  is  of  little  value  as  a  con- 
firmatory symptom,  because,  as  has  just  been  said,  the  liver  is  dispro- 
portionately large  in  infancy  and  it  is  difficult  to  state  the  limit  beyond 
which  abnormality  begins.  Moreover,  causes  other  than  congenital 
syphilis  lead  to  its  enlargement. 

The  importance  of  splenic  enlargement  is  greatest  when  noticed  early, 
— the  first  three  months  after  birth,— since  at  this  period  enlargement 
of  the  spleen  due  to  rachitis  can  hardly  come  into  question. 

The  Pancreas. — Diffuse  interstitial  infiltration  of  the  pancreas 
has  been  found  in  a  certain  percentage  of  the  more  malignant  cases 
of  hereditary  syphilis.  There  are  probably  no  symptoms  which  will 
assist  in  the  detection  of  this  involvement  during  life,  and  it  is  always 
associated  with  lesions  of  other  organs  far  more  serious  and  demand- 
ing more  immediate  attention. 

The  Intestines. — During  the  early  secondary  period  lesions  cor- 
responding in  type  to  those  appearing  on  the  skin  may  attack  the 
intestines.  The  passage  of  blood  by  the  bowel  would  probably  be 
the  only  sign  on  which  a  diagnosis  could  be  formed.  Ulcerating,  gum- 
matous infiltrations,  rare  in  any  event,  are  more  common  in  congeni- 
tal than  in  acquired  syphilis,  though  it  must  be  remembered  that  this 
statement  is  founded  on  examinations  of  malignant  and  fatal  cases  of 
congenital  syphilis. 

The  Kidneys. — Cassell  reports  six  cases  of  albuminuria  in  thirty- 
one  infants  with  inherited  syphilis.  Interstitial  and  peri-adventitial 
proliferation  and  cystic  degeneration  of  the  glomeruli  were  the  lesions 
found. 

HEREDITARY   SYPHILIS   AFFECTING  THE   TESTICLES. 

This  rare  manifestation  of  hereditary  syphilis  usually  develops  in 
the  first  year  of  life.  The  testicle  slowly  and  painlessly  enlarges. 
The  epididymis  may  be  involved  in  the  swelling,  and  there  may  be 
an  associated  hydrocele.  Softening  and  ulceration  rarely  occur,  reso- 
lution ultimately  taking  place,  often  followed  by  pronounced  atrophy 
of  the  gland. 

Diagnosis. — Non-traumatic  enlargement  of  the  testicle  in  infancy 
should  always  suggest  syphilis  or  tuberculosis.     If  the  tumor  never 


998  GENITO-UEINAEY   DISEASES   AND   SYPHILIS. 

reaches   great   size,  shows   no  tendency  to  ulcerate,  and  primarily 
attacks  the  testes,  it  is  probably  syphilitic. 
Prompt  treatment  will  prevent  atrophy. 

DIAGNOSIS  OF   INHERITED   SYPHILIS. 

In  reviewing  the  general  course  of  a  case  of  inherited  syphilis  it 
becomes  evident  that  the  differences  between  it  and  the  acquired  dis- 
ease are  seeming  rather  than  real.  The  primary  stage  in  inherited 
syphilis  is  of  course  wanting,  and  the  tertiary  stage  is  apt  to  appear 
unusually  early. 

Early  Hereditary  Syphilis. — ^The  diagnosis  of  inherited  syphilis  in 
its  early  stages,  at  birth  and  shortly  after,  will  be  founded  on, — 

1.  A  history  of  parental  syphilis.  The  probability  of  the  trans- 
mission of  the  disease  is  increased  if  the  parental  syphilis  was  recent 
at  the  time  of  conception  and  if  both  parents  were  infected. 

2.  A  history  of  abortions  or  miscarriages  on  the  part  of  the  mother, 
particularly  if  such  accidents  have  been  frequent,  or  of  the  successive 
births  of  several  living  children  who  survived  but  a  short  time. 

3.  A  foetus  or  still-born  child  showing  (a)  osteochondritis,  readily  de- 
tected by  splitting  the  long  bones,  particularly  the  radius,  ulna,  humerus, 
tibia,  and  femur,  througli  the  diaphyso-epiphyseal  juncture.  In  place 
of  the  regular  narrow  line  marking  the  apposition  of  bone  to  cartilage, 
there  is  a  broad,  irregular,  yellow  line  ;  (6)  enlargement  of  the  liver  and 
spleen ;  (c)  the  lesions  of  interstitial  pulmonitis ;  true  gummata,  or 
catarrhal  phenomena,  with  fatty  degeneration ;  (d)  papular,  pustular, 
or  ulcerating  lesions,  or  bullae  which  exhibit  the  characteristics  of 
syphilitic  pemphigus.  Maceration  of  the  epidermis  and  its  elevation 
into  bullae  are  scarcely  characteristic,  though  distinctly  suspicious, 
(e)  Arachnitis  with  hydrocephalus.  (/)  Arrested  development  and 
evidence  of  profound  malnutrition. 

4.  A  living  child  prematurely  born,  or  carried  to  full  term,  show- 
ing the  lesions  of  syphilis  at  birth  or  shortly  developing  them. 
Whether  the  syphilitic  child  be  stunted,  emaciated,  wizened,  and 
senile  at  birth,  or  be  well  nourished,  cutaneous  or  mucous  membrane 
eruptions  and  other  evidences  of  syphilis  are  often  absent.  In  a  few 
weeks,  or  at  most  two  or  three  months,  highly  characteristic  symp- 
toms develop.  The  more  prominent  of  these  are  snuffles,  hoarseness 
of  the  voice,  syphilides  of  the  skin  and  mucous  membrane,  enlarge- 
ment of  the  liver  and  spleen,  inflammation  of  the  iris,  profound  ca- 
chexia, and  specific  inflammation  at  the  junction  of  the  epiphyses  and 
diaphyses  of  the  long  bones,  sometimes  producing  a  condition  termed 
syphilitic  pseudo-paralysis. 


HEKEDITAEY   SYPHILIS. 


999 


Upon  the  presence  of  these  symptoms  the  diagnosis  of  hereditary 
syphihs  will  be  founded  in  the  first  year  in  life. 

Prognosis. — The  prognosis  of  early  hereditary  symptoms  is  unfavor- 
able if  cachexia  is  marked,  if  there  are  intercurrent  affections,  if  the 
symptoms  show  themselves  early,  if  the  nasal  or  laryngeal  affection  is 
severe,  if  the  eruptions  are  markedly  bullar  or  pustulo-ulcerative,  if  the 
enlargement  of  the  spleen  is  great,  if  the  osseous  lesions  are  multiple 
or  extensive,  and  especially  if  lesions  of  the  tertiary  type  develop, 
such  as  gummata,  nodes,  etc. 

Late  Hereditary  Syphilis. — After  infancy  the  diagnosis  of  inherited 
syphilis  will  be  founded  on, — 

1.  A  history  of  parental  or  infantile  syphilis,  or  both. 

2.  Imperfect  or  arrested  development.  This  is  manifested  by  many 
symptoms,  none  of  which  are  individually  characteristic,  but  the  as- 
sociation of  which  is  pathognomonic.  The  common  expressions  of 
this  developmental  retardation  or  arrest  are — 

.  {a)  A  low  stature  and  puny  development.  The  figure  is  often 
graceful  and  symmetrical,  suggesting  infantilism  or  early  youth  long 
after  these  periods  have  passed,  or  the  appearance  may  be  that  of 
premature   senility.      (6)  Pasty, 

leaden,  or  earthen  complexion.  ^'^-  ^l^- 

(c)  Dryness  or  harshness  of  the 
hair,  and  brittleness  and  split- 
ting of  the  nails. 

3.  Active  manifestations  of 
syphilis  or  traces  of  former  char- 
acteristic lesions,  (a)  The  fore- 
head bulging  in  the  middle  line, 
or  bossed  in  the  region  of  the 
frontal  and  parietal  eminences. 
(6)  A  flat,  sunken  bridge  of 
the  nose,  due  to  the  coryza 
of  infancy  extending  to  the 
periosteum  of  the  delicate  nasal 
bones,  interfering  with  their 
nutrition  or  partially  destroying 
them,  (c)  Dulness  of  the  iris 
(rare). 

4.  Ulceration  of  the  hard  pal- 
ate and  pharynx.     Thickening  or  enlargement  of  the  long  bones  near 
the  ends,  or  slight  angular  deformity,  the  result  of  the  osteochondritis 
of  infancy. 


Hereditary  syphilis.  Cicatrices  of  fissured 
lips  and  gummata  of  the  forehead  and  orbit.  (De 
Schweinitz.) 


1000  GENITO-UKINAEY  DISEASES   AND   SYPHILIS. 

5.  Hutchinson's  teeth, 

6.  Traces  of  interstitial  keratitis. 

7.  Cicatrices  about  the  hps  and  nares.  These  appear  in  the  form 
of  narrow,  radiating  scars,  extending  across  the  mucous  membrane  of 
the  lips,  or  as  a  net-work  of  linear  cicatrices  on  the  upper  lip  and 
around  the  nostrils,  as  well  as  at  the  corners  of  the  mouth  and  on  the 
lower  lip.     (Fig.  314.) 

8.  Skin  cicatrices,  showing  rounded,  polycyclic,  or  serpiginous 
outlines,  especially  about  the  nose  and  the  gluteal  region. 

9.  Periosteal  nodes  on  one  or  many  of  the  long  bones,  or  irregu- 
larly scattered  over  the  skull. 

10.  Sudden  and  complete  deafness  without  otorrhcea,  or  other 
subjective  symptoms,  or  a  history  of  sudden,  painless  otorrhoea  in 
childhood. 

Prognosis. — The  prognosis  of  late  hereditary  syphilis  is  good  so 
far  as  life  is  concerned,  although  exceptionally  when  important  vis- 
cera, such  as  the  lungs,  the  brain,  the  liver,  or  the  kidneys,  are  at- 
tacked, death  may  result  before  treatment  can  accomplish  resolution 
of  the  specific  infiltrate. 

The  treatment  of  hereditary  syphilis  is  given  in  the  followmg 
chapter. 


CHAPTER   XXVIII. 

THE  TREATMENT  OF  SYPHILIS. 

The  treatment  of  syphilis  is  conveniently  considered  under  the 
following  heads : 

1.  Prophylactic. 

2.  Abortive. 

3.  Constitutional. 

4.  Local. 

PROPHYLACTIC  TREATMENT. 

In  discussing  the  treatment  of  a  disease  which  is  thought  to  owe 
its  origin  to  a  pathogenic  organism,  modern  science  demands  consid- 
eration of  the  possibility  of  preventing  the  spread  of  the  contagion,  or 
of  eradicating  it  by  destroying  the  source  of  infection. 

The  Contagious  Diseases  Acts  of  Great  Britain  and  the  various  laws 
of  other  countries  for  the  restriction  and  regulation  of  prostitution  aim 
at  accomplishing  this  purpose.  They  represent  the  attempts  of  the 
governing  authority  to  protect  the  community  at  large  from  disease 
and  infection  by  regulating  the  hygiene  of  and  placing  restrictions  on 
the  class  most  liable  to  spread  the  disease.  There  can  be  no  doubt  that 
these  measures  are  of  great  benefit,  and  it  has  been  proved  that  clan- 
destine prostitution,  out  of  reach  and  control  of  these  acts,  is  the  great 
source  of  contagion  in  the  countries  in  which  they  have  been  in  force. 

It  may  be  admitted  that  no  method  has  as  yet  been  devised  which 
is  in  all  respects  unobjectionable  or  is  capable  of  universal  application. 
It  may  also  be  conceded,  even  while  advocating  the  general  principle 
of  supervisory  legislation  as  applied  to  prostitution,  that  in  the  details 
of  every  plan  yet  proposed  there  has  been  much  that  was  defective 
or  positively  harmful,  and  that  the  subject  is  still  one  of  the  unsolved 
sanitary  problems  of  the  age.  The  direction  in  which  action  must  be 
taken,  and  the  general  character  of  that  action,  may,  nevertheless,  be 
indicated,  if  not  demonstrated. 

We  may  begin,  without  much  fear  of  contradiction,  by  urging  the 
necessity  of  a  more  general  and  more  accurate  public  knowledge  con- 
cerning the  gravity  and  the  prevalence  of  this  disease.  The  innocent — 
who  are  also  in  this  respect  the  ignorant — members  of  the  community 
have  claims  which  we,  who  seek  to  fulfil  the  highest  function  of  our  pro- 

1001 


1002  GENITO-UEINAET  DISEASES   AND   SYPHILIS. 

fession, — the  preservation  of  health,  individual  and  national, — cannot 
conscientiously  disregard.  Every  adult  citizen  should  be  aware  for  his 
own  sake  of  the  possibilities  of  contamination  which  surround  him ; 
every  parent  should  be  competent  to  protect  his  wife  or  children  from 
all  indirect  infection  through  a  servant  or  playmate,  a  household  uten- 
sil or  a  toy ;  every  wife  should  know  that  by  permitting  the  approaches 
of  a  syphilitic  husband  she  herself  becomes  liable  to  disease,  and  to 
the  creation  of  a  being  which  has  few  chances  for  life  and  still  fewer 
for  health  and  happiness ;  and  every  syphilitic  should  realize  that,  ex- 
cept after  certain  intervals  and  under  proper  restrictions,  his  marriage 
is  an  outrage  to  the  woman  he  professes  to  love  and  a  crime  against 
society. 

Once  let  these  facts  be  clearly  understood  and  this  information 
widely  diffused,  and  an  important  step  will  have  been  taken  not  only 
in  preventing  accidental  and  guiltless  contagion,  but  also  in  preparing 
public  opinion  for  the  legislative  measures  which  are  believed  to  be 
desirable.  Another  good  result  would  in  all  probability  be  a  diminu- 
tion in  the  number  of  cases  of  this  class  of  disease,  who,  in  ignorance 
of  the  gravity  of  their  ailment,  consult  the  quacks  and  irregular  prac- 
titioners who  find  here  their  favorite  and  lucrative  field.  It  is  safe  to 
say  that  the  fees  of  the  patients  vv' ith  venereal  disease  annually  treated 
by  charlatans,  advertising  doctors,  and  apothecaries  would  comfort- 
ably support  all  those  younger  members  of  the  profession  into  whose 
hands  they  ought  naturally  to  fall  and  who  now  pass  through  the 
usual  struggle  for  existence. 

For  these  reasons — first  and  especially  the  public  welfare,  and 
next  our  own  personal  interest — we  should  in  every  proper  way  en- 
courage the  presentation  of  this  matter  to  the  community  at  large,  by 
means,  for  example,  of  discussions  in  health  societies,  by  proper  repre- 
sentations to  editors  of  the  daily  press,  and  by  careful  but  truthful  and 
forcible  statements  to  our  friends  and  patients,  who  are  frequently 
eager  for  information  on  the  subject. 

It  may  be  admitted  at  once  that  if  the  total  abolition  of  prostitution 
could  be  accomplished,  and  if  it  could  be  followed  by  the  conversion 
of  the  army  of  harlots  into  peaceful  housekeepers  or  sisters  of  charity, 
and  the  transformation  of  their  male  patrons  into  pure,  law-abiding 
citizens  and  fathers  of  families,  it  would  be  a  most  satisfactory  con- 
summation. No  one,  however,  at  the  present  day,  with  perhaps  the 
exception  of  a  few  impractical  clergymen  and  a  number  of  enthusias- 
tic and  well-meaning  but  misguided  women,  believes  in  the  possibility 
of  attaining  such  an  end.  The  accumulated  experience  of  mankind 
constitutes  a  wall  of  unanswerable  argument.     All  attempts  at  the  ex- 


THE   TREATMENT   OF   SYPHILIS.  1003 

tinction  of  prostitution  present  throughout  the  centuries  one  unbroken 
record  of  failure.  Wherever  this  scheme  has  been  tried,  the  sexual 
impulse,  the  strongest  to  which  human  nature  is  subject,  has  asserted 
itself,  and  other  laws  have  been  violated,  other  and  graver  evils  have 
resulted.  The  remedy  has  proved  worse  than  the  disease.  (Lecky.) 
Seduction,  illegitimacy,  criminal  abortion,  and  infanticide  have  invari- 
ably followed,  and  the  total  average  mortality  of  the  community  has 
been  seriously  increased. 

In  considering  the  necessity  for  general  prophylaxis  and  the  direc- 
tion which  efforts  towards  the  accomplishment  of  this  end  should  take, 
it  should  be  remembered : 

1.  That  syphilis  is  of  great  antiquity,  and  is  likely  to  continue  in- 
definitely. 2.  That  this  disease  already  affects  a  large  number  of  the 
population,  and  that  by  means  of  its  many  forms  of  inoculation  and 
transmission  it  is  rapidly  spreading  still  farther.  3.  That  the  existing 
means  for  its  treatment  among  the  poorer  classes  are  insufficient,  and 
that  the  establishment  of  institutions  for  that  purpose  or  the  endow- 
ment of  special  wards  in  our  general  hospitals  is  a  measure  eminently 
worthy  of  the  attention  of  the  public-spirited  and  benevolent.  4,  That 
its  most  common  mode  of  propagation  is  by  irregular  or  illicit  sexual 
intercourse,  and  that  therefore  we  should  turn  our  main  efforts  at  pre- 
vention in  this  direction,  while  endeavoring  at  the  same  time  and  in 
every  decent  and  proper  manner  to  guard  the  community  at  large  from 
the  effects  of  ignorance.  5.  That  prostitution,  arising  in  response  to 
the  demand  for  this  illicit  indulgence,  has,  like  syphilis,  existed  from 
time  immemorial,  and  is  not  likely  to  disappear.  6.  That  prostitutes 
themselves  need  protection  and  have  claims  on  the  humanity  of  the 
law.  7.  That  by  means  of  supervisory  legislation  and  control  of  pros- 
titution the  unlawful  sexual  commerce  of  the  world  may  most  readily 
be  restricted  and  the  spread  of  the  disease  be  prevented.  8.  That 
there  is  sufficient  evidence  that  such  control  and  restriction,  though 
surrounded  with' difficulties,  is  yet  possible,  and  that  the  advantages  to 
be  derived  from  it  are  highly  important. 

The  only  certain  method  of  escaping  the  venereal  forms  of  syphilis 
is  the  avoidance  of  exposure.  When  consulted  in  regard  to  prophy- 
laxis the  physician  should  insist  upon  this  point  and  need  not  volun- 
teer further  information,  though  under  proper  circumstances  he  should 
not  withhold  knowledge  as  to  the  means  by  which  the  danger  of  con- 
tagion can  be  lessened,  if  not  entirely  avoided.  This  danger  can  be 
diminished  by  (1)  avoidance  of  intercourse  when  there  is  an  abrasion 
or  any  surface  break  about  the  genitalia ;  (2)  the  use  of  covers ;  (3) 
the  local  use  of  protective  and  antiseptic  ointments  ;  (4)  thorough  local 


1004  GENITO-UEINAEY   DISEASES  AND  SYPHILIS. 

washings  with  mild  antiseptic  lotions  immediately  before  and  imme- 
diately after  coitus ;  (5)  circumcision  in  persons  with  redundant  or 
phimotic  foreskins  ;  (6)  the  use  of  astringents  by  those  whose  mucous 
membrane  is  particularly  vulnerable ;  (7)  immediate  antiseptic  appli- 
cations to  and  superficial  cauterization  of  abrasions  acquired  during 
coitus.     An  inunction  of  calomelol  ointment  is  fairly  efficient. 

The  risks  of  extragenital  infection  are  lessened  by  (1)  the  avoid- 
ance of  prolonged  contact  of  any  portions  of  the  body ,  this  particularly 
holds  true  of  the  lips  and  tongue ;  (2)  care  as  to  the  cleanliness  of 
eating  and  drinking  utensils,  pipes,  or  any  article  which  is  liable  to  be 
contaminated  by  the  discharge  from  the  lesions  of  syphilitics  ;  (3)  the 
immediate  cauterization  of  any  abrasion  or  wound  which  could  pos- 
sibly have  been  infected  by  the  discharges  from  syphilitic  lesions. 

Perhaps  the  most  important  means  of  prophylaxis  is  thoroughly  to 
impress  upon  those  who  are  suffering  from  florid  syphilis  the  fact  that 
all  their  bodily  secretions  are  hable  to  be  contagious.  They  must  be 
instructed  as  to  the  possibility  of  infecting  others  from  cigars,  spoons, 
forks,  or  other  articles  moistened  with  their  sahva,  or  from  razors, 
manicure  instruments,  scissors,  or  knives  which  may  be  stained  by 
their  blood,  and  from  handkerchiefs,  sheets,  pihow-cases,  garments, 
towels,  sponges,  or  baths  which  may  contain  the  virulent  discharge 
from  mucous  membrane  or  skin  lesions. 

The  danger  of  conveying  the  contagion  by  kissing,  by  intercourse, 
or  by  body  contact  of  any  kind  must  be  clearly  laid  down. 

In  the  case  of  a  surgeon,  accoucheur,  or  dentist,  the  possibility 
of  infecting  patients  by  means  of  the  blood  incident  to  accidental 
wounds  of  the  hands  must  be  duly  considered  ;  indeed,  this  danger  is 
sufficiently  pronounced  to  forbid  the  performance  of  difficult  or  exten- 
sive operations  during  the  florid  stage  of  the  disease. 

As  further  means  of  prophylaxis,  barbers,  masseurs,  chiropodists, 
all  whose  occupation  requires  them  to  treat  the  skin  and  its  appen- 
dages by  instruments  or  by  the  hands,  should  be  thoroughly  in- 
structed as  to  the  possibility  of  conveying  the  disease.  They  should 
be  required  to  sterilize  their  instruments  by  heat  or  other  efficient 
means  before  using  them  on  each  new  chent,  and  should  be  held 
legally  responsible  for  cases  of  syphiHs  which  develop  in  consequence 
of  their  ignorance  or  neglect  of  simple  precautions. 

THE  ABORTIVE  TREATMENT. 
Two  methods  have  been  proposed  for  the  abortion  of  syphilis 
immediately  upon  the  appearance  of  chancre  ;  these  are — 


THE   TREATMENT   OF   SYPHILIS.  1005 

1.  The  excision  or  complete  destruction  of  the  chancre  and  the 
surrounding  tissues. 

2.  Destruction  of  the  specific  virus  by  active  constitutional  treat- 
ment. 

Excision  or  Destruction  of  the  Chancre. — The  abortion  of 
syphilis  by  excision,  cauterization,  or  injection  of  the  chancre  has  been 
attempted  in  many  hundreds  of  cases,  but  efforts  in  this  direction 
have  almost  without  exception  proved  futile.  In  a  very  few  of  the 
many  reported  cases  excision  seemed  to  be  successful  in  preventing 
the  development  of  constitutional  disease  ;  but  it  is  possible  that  con- 
stitutional syphilis  would  not  have  developed  even  if  the  operation 
had  not  been  undertaken,  since  the  course  of  untreated  cases  shows 
that  a  certain  small  percentage  of  undoubted  chancres  is  not  followed 
by  secondary  manifestations. 

Aside  from  the  attempt  to  abort  syphilis,  excision  of  the  chancre 
may  be  undertaken  with  the  idea  of  ridding  the  system  of  a  focus  of 
infection,  or  for  cosmetic  or  other  reasons,  and  if  total  excision  does 
not  leave  a  deforming  or  crippling  scar  there  can  be  no  objection  to 
it.  It  must  be  borne  in  mind,  in  considering  the  results  of  this  opera- 
tion, that  the  ulceration  of  chancre,  even  though  it  appear  extensive 
and  deep,  usually  disappears  under  constitutional  treatment,  leaving 
an  extremely  insignificant  scar.  Ehler  holds  that  excision  of  the  initial 
lesion  lessens  the  severity  of  subsequent  symptoms,  since  thus  there 
is  cut  off  from  the  system  a  large  amount  of  infection ;  he  also  thinks 
that  in  a  certain  percentage  of  cases  the  constitutional  disease  is  com- 
pletely aborted.  Fournier  beheves  that  excision  gives  an  average  of 
one  success  in  five  cases. 

Probably  it  is  safe  to  assume  that  when  the  sore  is  seen  within  a 
few  days  of  its  appearance  and  before  the  lymphatic  vessels  and 
glands  in  anatomical  connection  are  enlarged,  the  disease  may  still  be 
purely  local,  and  constitutional  poisoning  may  be  prevented  by  com- 
plete excision  of  the  infected  focus :  hence  such  a  sore  should  be  re- 
moved by  excision  when  it  is  favorably  located  for  this  operation,  or 
should  be  destroyed  by  cauterization  under  other  circumstances. 
When  the  sore  is  located  upon  the  prepuce  or  upon  the  skin  of  the 
genitalia,  it,  together  with  the  apparently  healthy  surrounding  tissue, 
may  be  picked  up  in  a  pair  of  rat-tooth  forceps  and  removed  by  a 
cut  with  a  pair  of  scissors  curved  on  the  flat.  This  wound  may  be 
sutured,  or,  to  give  greater  assurance  of  the  complete  destruction  of 
the  specific  micro-organisms,  the  raw  surface  may  be  cauterized  with 
nitric  acid  and  dressed  with  iodoform  or  boric  acid  powder.  When 
the  sore  is  so  situated  that  its  removal  by  the  knife  would  cause 


1006  GENITO-rKINAEY   DISEASES   AND   SYPHILIS. 

troublesome  hemorrhage,  deformity,  or  interference  Avith  function, 
nitric  acid  or  the  actual  cautery  may  be  employed  for  its  destruction. 

As  regards  protection  from  subsequent  constitutional  syphihs,  the 
results  are,  on  the  whole,  unsatisfactory ;  but  in  a  few  cases — nine  in 
all — we  have  been  able  to  make  observations  under  unusually  satis- 
factory circumstances.  In  these  cases  the  patients  came  promptly 
upon  the  development  of  the  sore,  and  sent  for  examination  the 
women  with  whom  they  had  had  connection,  evidence  of  syphihs  being 
discovered  in  the  latter.  The  sores  of  the  male  patients  were  excised 
and  cauterized  with  nitric  acid.  In  five  of  these  cases  microscopical 
examinations  showed  that  the  sores  possessed  the  usual  characteris- 
tics of  hard  chancre.  In  one  of  them  slight  glandular  involvement 
had  already  shown  itself;  in  the  others  it  had  not  yet  appeared.  The 
shortest  period  intervening  between  the  appearance  of  the  sore  and 
inspection  of  it  was  twelve  hours  ;  the  longest,  five  days. 

In  five  of  the  nine  cases,  includiag  the  one  in  which  there  was 
slight  glandular  involvement,  no  further  symptoms  have  ever  devel- 
oped ;  in  the  remaining  four  the  appearance  of  constitutional  symp- 
toms was  delayed  from  three  to  five  weeks  beyond  the  usual  time, 
just  as  is  the  case  when  mercury  is  given  immediately  on  the  appear- 
ance of  chancre. 

It  is  only  fair  to  add  that,  during  the  time  these  observations  were 
made,  several  cases  were  seen  in  which  excision  was  not  performed 
on  account  of  the  anatomical  seat  of  the  sores,  which  were  believed  to 
be  almost  certainly  specific,  but  which  healed  and  disappeared  with- 
out the  development  of  the  slightest  constitutional  trouble.  Only  in 
one  of  these  latter  cases,  however,  was  there  an  opportunity  for  con- 
firming the  diagnosis  by  confrontation. 

In  all  cases  in  which  a  week  or  more  has  elapsed  since  the  devel- 
opment of  the  sore,  and  in  which  involvement  of  the  dorsal  lym- 
phatics of  the  penis  or  of  the  inguinal  lymphatic  glands  is  observable, 
cauterization,  as  a  routine  method  of  treatment,  should  be  rejected,  on 
account  of  its  undoubted  uselessness  at  that  stage  in  preventing  con- 
stitutional disease  ;  the  pain  which  it  causes  ;  the  inflammatory  action 
which  follows  it,  and  which  often  produces  enough  oedema  and  swell- 
ing to  cause  phimosis,  and  thus  convert  an  open  sore  into  a  hidden 
one ;  the  subsequent  effusion  of  lymph,  which  simulates  true  indura- 
tion and  confuses  the  diagnosis ;  and,  finally,  the  greater  liability  to 
the  production  of  suppurative  action  in  the  ordinarily  indolent  bubo 
of  syphilis. 

Even  though  the  sore  has  not  been  seen  for  one  or  two  weeks  and 
the  inguinal  glands  are  typically  enlarged,  if  situated  upon  a  surface 


THE   TREATMENT   OF   SYPHILIS.  1007 

from  which  it  can  be  removed  without  resulting  deformity,  it  should 
be  excised,  the  resulting  wound  being  sutured.  When  situated  entirely 
on  the  foreskin,  whether  seen  early  or  late  in  its  development,  total 
removal  by  circumcision  is  desirable. 

Constitutional  Abortive  Treatment. — The  more  prompt  and  vig- 
orous the  treatment  the  more  assured  the  cure  of  the  disease,  as  demon- 
strated by  the  absence  on  repeated  trial  of  the  Wassermann  reaction. 
Hence,  mercury  should  be  given  as  soon  as  the  diagnosis  of  syphilis  is 
made.  The  probable  diagnosis  is  made  on  the  history  and  the  clinical 
findings,  the  absolute  diagnosis  is  based  on  finding  the  Treponema 
pallidum. 

THE  CONSTITUTIONAL  TREATMENT  OF  SYPHILIS. 

The  constitutional  treatment  of  syphilis  should  be  instituted  the 
moment  the  diagnosis  is  assured.  The  likelihood  of  radical  elimina- 
tion of  the  infection  is  proportionate  to  the  vigor  and  timeliness  of 
treatment.  The  constitutional  infection  may  be  first  manifested  by  a 
rash,  general  lymphatic  involvement,  muscular,  neuralgic,  or  bone 
pains,  anaemia,  or  the  so-called  syphilitic  fever,  though  commonly  the 
rash  is  the  most  characteristic  and  most  easily  recognized  sign  of  sys- 
temic involvement  on  which  the  surgeon  can  base  his  diagnosis.  After 
the  fourth  week  the  Wassermann  reaction  is  nearly  always  positive. 

The  general  health  of  the  patient  should  be  carefully  regulated.  He 
must  be  warned  as  to  the  importance  of  avoiding  overwork,  mental 
strain,  undue  exposure,  and  excesses  of  all  kinds.  He  should  eschew 
strong  alcoholic  drinks,  but  need  not  be  prohibited  from  moderate 
indulgence  in  light  wines  at  meals.  He  should  be  cautioned  that  the  use 
of  tobacco  distinctly  predisposes  to  lesions  of  the  mouth  and  throat,  and 
should  be  advised  to  give  up  the  use  of  this  drug  in  all  its  forms. 

The  hereditary  tendencies  and  diathesis  of  each  individual  should 
be  studied,  since  every  depressing  influence  by  lessening  cell-resist- 
ance may  lead  to  increased  virulence  of  the  disease.  Tuberculosis  in 
the  form  clinically  recognized  as  struma  particularly  favors  virulent 
manifestations  of  syphilis,  such  as  deep  and  obstinate  ulceration,  os- 
titis, caries,  and  various  visceral  changes.  A  tubercular  family  history 
should,  therefore,  be  regarded  as  a  special  indication  for  hygienic 
precautions.  A  patient  with  such  a  history  should  spend  at  least  a 
part  of  each  summer  at  the  sea-shore  or  in  the  mountain  air,  should 
avoid  all  causes  of  local  congestion,  such  as  chilling  of  the  surface, 
and  particularly  should  guard  against  bruises,  sprains,  or  other  trau- 
matisms, slight  in  themselves,  but  strongly  predisposing  to  the  local 
development  of  strumous  and  of  syphilitic  lesions.  The  diet  should 
be  rich,  of  digestible  fats,  and  carbohydrates.     Pulmonary  gymnastics 


IQQg  GEI^ITO-UEINAEY   DISEASES   AND   SYPHILIS. 

should  be  employed,  and  to  the  specific  treatment  should  be  added 
emulsions  of  partly  digested  cod-liver  oil  in  combination  with  ferrous 
iodide  or  the  hypophosphites. 

Both  the  gouty  and  the  rheumatic  diathesis  exert  a  distinctly  un- 
favorable influence  on  the  course  of  syphilis.  They  predispose  to  vas- 
cular degeneration,  to  cerebral  disease  secondary  to  endarteritis,  to 
troublesome  papulo-squamous  syphilides,  to  iritis,  to  periosteal  nodes 
and  various  other  affections  of  the  fibrous  tissue.  The  diet  of  such 
patients  should  be  most  carefully  regulated.  They  should  be  told  to 
eat  sparingly  of  dark  meats  and  of  sugars,  to  drink  freely  of  potash 
or  lithia  waters,  and  to  eschew  sweet  wines,  malt  hquors,  etc.  In 
combination  with  the  above  treatment,  short  courses  of  salicylates 
may  be  advantageously  employed,  and  the  iodides  should  be  begun 
much  earlier  than  in  the  case  of  previously  healthy  patients. 

Patients  of  a  neurotic  type  seem  to  be  especially  predisposed  to 
affections  of  the  brain  and  spinal  cord.  The  preliminary  advice  in 
such  cases  must  be  directed  to  the  avoidance  of  worry  and  mental 
strain  of  any  kind.  Every  effort  should  be  made  to  prevent  that  state 
of  nervous  depression  which  the  knowledge  of  having  contracted 
syphilis  so  often  occasions.  Rest  to  the  mind,  and  diversions.of  vari- 
ous kinds,  particularly  those  which  require  mild  exercise,  such  as 
horseback  riding,  cycling,  golf,  and  long  summer  vacations  spent  in 
the  open  air,  should  be  insisted  upon.  The  treatment  should  be  un- 
obtrusive, the  prognosis  to  the  patient  hopeful.  Long  hours  of  rest 
are  particularly  desirable.  The  specific  treatment  may  be  advan- 
tageously supplemented  by  strychnine  and  the  hypophosphites. 

In  all  patients,  whether  robust  or  weak,  the  hygiene  of  the  mouth, 
of  the  gastro-intestinal  tract,  and  of  the  skin  should  receive  particular 
attention,  and  invariably  repeated  examinations  of  the  urine  should 
be  made  to  determine  whether  or  not  the  kidneys  can  be  depended 
on  for  the  elimination  of  mercury  and  possibly  the  toxic  products  of 
the  syphilitic  virus. 

The  teeth  should  be  put  in  perfect  order  by  a  competent  dentist, 
and  should  be  kept  scrupulously  clean  through  the  entire  course  of 
treatment  by  cleansing  washes,  astringent  mildly  antiseptic  powders, 
and  careful  removal  of  particles  of  food  by  means  of  toothpicks  and 
dental  floss  immediately  after  eating.  Upon  the  health  of  the  mucous 
membrane  of  the  mouth  depends  to  a  great  extent  the  ability  of 
the  patient  to  take  an  efficient  quantity  of  mercury  without  causing 
salivation. 

The  gastro-intestinal  tract  must  be  kept  free  from  irritation  by 


THE   TKEATMENT   OF   SYPHILIS.  1009 

well-regulated  diet,  by  digestive  and  antiseptic  powders,  and  by  mild 
laxatives  when  indicated.  Only  when  the  stomach  and  bowels  are  in 
good  condition  can  the  full  dose  of  mercury  be  taken  by  the  mouth  and 
be  absorbed  without  exciting  symptoms  of  gastro-intestinal  catarrh. 
The  bowels  aid  in  the  elimination  of  mercury. 

The  skin  also  aids  in  eliminating  mercury.  It  should  be  kept  in 
perfect  health  by  daily  bathing  and  friction,  hot  or  cold  water  being 
employed  in  accordance  with  the  feelings  of  the  patient.  Hot  plunge 
baths,  Turkish  baths,  and  hot-air  baths  are  to  be  advised,  unless 
marked  vascular  degenerations  contra-indicate  their  employment. 

Interrupted  treatment  of  syphilis  is  worthy  of  serious  con- 
sideration mainly  because  it  is  advocated  by  Fournier.  He,  how- 
ever, has  frequently  changed  his  method,  and  this  fact  apparently 
shows  that  the  intermittent  course  has  often  failed  to  produce  per- 
manent cures. 

Taylor  holds  that  the  time  to  eradicate  syphilis  is  at  the  beginning 
of  the  attack,  when  vigorous  mercurial  treatment  is  best  tolerated  and 
is  most  efficient.  If  the  treatment  is  pushed  for  about  six  months  he 
believes  that  most  cases  will  be  found  on  their  way  to  recovery,  and 
may  then  have  a  rest  in  the  absence  of  lesions  and  if  the  general  health 
is  well  maintained.  After  a  month  without  specific  treatment  a  course 
of  inunctions,  or  a  combination  of  mercury  and  small  doses  of  potas- 
sium iodide,  is  given.  Taylor  argues  against  the  continuous  plan  of 
treatment,  on  the  ground  that  mercury  administered  by  the  stomach  in- 
duces a  condition  of  tolerance  and  after  a  time  has  no  beneficial  effect. 

Continuous  Treatment. — This  is  the  most  rational  treatment 
of  syphilis,  and  is  the  one  which  is  generally  adopted.  Mercury  is 
administered  without  interruption  for  a  period  varying  between  one 
and  three  years,  and  in  as  full  doses  as  the  patient  can  tolerate  without 
prejudice  to  general  health.  It  is  advisable  to  use  the  same  prepara- 
tion of  mercury  throughout  the  treatment.  The  dose  is  regulated  by 
the  patient's  susceptibility.  The  first  symptoms  caused  by  full  dosage 
of  the  protiodide  may  be  griping  pains  in  the  abdomen  and  several 
watery  stools  a  day.  When  other  preparations  of  mercury  are  given, 
and  often  with  the  protiodides,  fetor  of  the  breath,  hypersecretion  and 
ropiness  of  the  saliva,  and  slight  gum  tenderness  may  be  the  first 
indications  that  the  drug  has  been  pushed  beyond  the  limit  of  safety. 
The  development  of  syphilitic  lesions  is  indicative  of  an  inadequate 
dose  of  mercury.  The  entire  absence  of  lesions,  and  a  condition  of 
general  good  health,  are  indicative  of  a  proper  dosage.  Loss  of  weight 
and  general  malaise  may  be  indicative  of  either  too  much  or  too  little 
mercury.     The  proper  dosage  of  mercury  is  that  which  completely 


1010  GENITO-URINARY   DISEASES   AND    SYPHILIS. 

controls  the  disease  and  manifests  none  of  the  toxic  effects  of  the 
drug.  The  gauge  of  efficient  treatment  is  the  health  of  the  patient. 
Frequently,  as  a  result  of  treatment,  there  is  an  increase  in  general 
health,  markedly  beyond  the  degree  enjoyed  before  syphilitic  infection. 

SYSTEMATIC  TREATMENT  OF  SYPHILIS. 

As  a  result  of  many  years  of  experience  in  large  venereal  hospital 
services  and  a  somewhat  exceptionally  rich  clientele  in  private  prac- 
tice, we  have  adopted  the  following  routine  method  of  treating  syphilis. 

The  general  hygienic  treatment  already  described  (pages  1007, 
1008)  is  inaugurated  at  once  ;  in  addition,  the  patient's  weight  is  re- 
corded and  repeated  quantitative  and  qualitative  examinations  of  the 
urine  are  made. 

Mercuric  treatment  should  be  practically  continuous  for  two  years, 
should  be  administered  with  rest  periods  for  two  more  years,  and 
should  be  given  spring  and  fall  for  life  unless  repeated  Wassermann 
tests  give  regular  results. 

As  to  the  preparation  of  mercury  which  is  to  be  administered,  the 
protiodide  is  preferable  for  routine  use,  because  clinically  it  has  been 
efficient,  and  possibly  because  the  small  amount  of  iodine  which  the 
salt  contains  may  be  advantageous.  Corrosive  sublimate  and  mercury 
with  chalk  will  also  give  excellent  results,  and  sometimes  can  be  taken 
without  irritation  when  the  protiodide  markedly  disagrees.  Blue  pill 
and  calomel  have  not  been  satisfactory. 

As  a  routine  practice  it  is  well  to  adhere  to  the  administration  of 
the  protiodide,  the  bichloride,  or  gray  powder,  preference  being  given 
to  the  first  drug,  the  others  being  employed  only  when  the  protiodide 
produces  undue  irritation  without  favorably  influencing  the  course 
of  the  disease. 

When  few  remedies  are  tried  by  the  surgeon  he  becomes  more 
familiar  with  their  strength  and  special  properties,  and  hence  is  more 
likely  to  employ  them  skilfully  than  if  he  used  many  salts  of  mercury, 
the  special  reactions  of  which  are  unknown  to  him. 

If  the  protiodide  is  selected,  the  following  prescription  may  be 
ordered : 

R    Hydrarg.  iodid.  flav.,  gr.  xxxiii  ; 

Confect.  ros.,  q.  s. 
M.   et  ft.  pil.  no.  c. 

The  patient  is  directed  to  take  three  pills  daily  for  the  first  three 
days,  four  for  the  second  three  days,  five  for  the  third,  and  so  increase 
the  dose  by  one  pill  every  third  day  until  some  characteristic  toxic 


THE    TREATMENT    OF    SYPHILIS.  IQll 

effect  of  the  drug  is  produced.  While  thus  pushing  mercury  for  the 
purpose  of  discovering  the  full  dose,  the  patient  must  be  seen  at  least 
every  third  day,  and  there  must  be  some  standard  adopted  by  which 
his  susceptibility  to  the  drug  may  be  determined, — that  is,  some  char- 
acteristic symptom  must  be  sought  for. 

The  patient's  reaction  to  the  drug  is  most  certainly  shown  by  fetor 
of  the  breath,  and  loss  of  weight  and  appetite.  Mild  colicky  diarrhoea 
is  frequently  considered  a  sign  that  the  full  dose  of  mercury  has  been 
reached;  this  symptom,  however,  shows  only  the  reaction  of  the 
intestinal  mucous  membrane  to  the  particular  preparation  of  mercury 
that  is  being  used.  Colic  and  diarrhoea  may  occur  long  before  enough 
mercury  has  been  given  to  influence  the  gums,  or  even  enough  to 
influence  the  course  of  early  syphilis.  These  symptoms  indicate  de- 
fective absorption  of  the  drug,  and  show  that  only  a  fractional  part  of 
the  daily  dose  administered  is  reaching  the  general  circulation  ;  hence 
the  adoption  of  colicky  diarrhoea  as  a  gauge  of  constitutional  suscep- 
tibility may  lead  to  error,  and  may  result  in  insufficient  treatment  and 
its  disastrous  consequences. 

If  during  early  treatment  colic  and  diarrhoea  develop  before  the 
manifestations  of  syphilis  are  markedly  influenced  for  the  better,  the 
protiodide  should  be  withdrawn,  and  in  its  place  pills  of  mercury  and 
chalk  should  be  administered  : 

B    Hydrarg.  cum  creta,   ^i  ; 
Ft.  pil.  no.  Ix. 

These  pills  are  administered  exactly  as  are  those  of  protiodide  of 
mercury,  beginning  with  three  pills  a  day  and  gradually  increasing  the 
dose  till  it  is  evident  that  the  lesions  are  rapidly  disappearing.  It 
cannot  be  too  strongly  urged  that  the  dose  of  mercury  in  the  treat- 
ment of  syphilis  is  the  largest  that  can  be  taken  without  producing 
symptoms  of  mercuric  intoxication,  or  injuriously  affecting  metabolism, 
and  that  even  a  mild  ptyalism  is  to  be  scrupulously  avoided,  since  it 
undoubtedly  increases  tissue  vulnerability.  When  mercury  is  being 
properly  administered  the  patient  in  addition  to  being  free  of  symp- 
toms characteristic  of  syphilis,  should  gain  rather  than  lose  in 
weight,  and  should  have  a  special  sense  of  well  being.  A  grain  of 
mercury  and  chalk  produces  a  somewhat  less  powerful  effect  than  the 
third  of  a  grain  of  protiodide. 

If  the  gastro-intestinal  irritation  persists,  unaccompanied  by  symp- 
toms of  ptyalism,  bichloride  of  mercury  should  be  administered : 

R    Hydrarg.  chlorid.  corrosiv. ,  gr.  iv  ; 
Confect.  ros.,  q.  s. 

M.  et  ft.  pil.  no.  Ix. 


1012  GENITO-URINARY   DISEASES  AND   SYPHILIS. 

or 

B  Hydrarg.  chlorid.  corrosiv.,  gr.  ii ; 
Mucilag.  acacise, 
Aquae,  aa  ,^ii. 
M.    S. — Teaspoonful  freely  diluted,  as  directed. 

If  the  change  to  these  prescriptions  is  not  successful  in  subduing  the 
symptoms  of  gastro-intestinal  irritation,  inunctions  must  be  employed. 

When  the  patient  is  so  situated  that  it  is  impossible  for  him  to 
take  inunctions,  opium  in  sufficient  quantity  to  control  the  diarrhoea 
may  be  combined  with  one  or  other  of  the  formulae  already  given  until 
the  full  dose  is  determined.  It  should  then  be  withdrawn,  since  it 
tends  to  constipate,  to  reduce  appetite,  and  geneially  to  influence  the 
system  unfavorably.  Moreover,  it  renders  uncertain  the  amount  of 
mercury  actually  being  absorbed,  and  this  is  a  disadvantage  of  cardinal 
importance,  since  the  essential  point  in  the  treatment  of  syphilis  is  the  ad- 
ministration during  a  sufficiently  long  period  of  the  largest  dose  of  mer- 
cury which  can  be  taken  and  absorbed  without  prejudice  to  the  general 
health.  Merely  to  order  that  a  certain  dose  of  mercury  be  swallowed 
and  to  provide  for  its  safe  escort  under  an  opiate  guard  from  one  end 
of  the  alimentary  tract  to  the  other,  is  not  to  treat  syphilis  intelli- 
gently. 

The  best  method  of  administering  opium,  when  this  is  required 
to  determine  the  full  dose,  is  in  the  form  of  paregoric.  With  each 
mercurial  pill  the  patient  is  directed  to  take  the  smallest  number 
of  drops  which  will  prevent  griping  diarrhoea ;  thus  the  minimum 
efficient  quantity  can  be  found  and  can  be  administered  in  a  form 
towards  which  the  stomach  is  fairly  tolerant. 

Salivation  is  never  to  be  produced,  and  the  drug  should  not  be 
pushed  to  the  development  at  early  symptoms  of  this  condition. 
These  are :  1,  fetor  of  the  breath  ;  2,  a  thickening  of  the  saliva  and 
an  increase  in  its  quantity  ;  3,  boggy  swelling  of  the  gums  around  the 
teeth,  and  a  tendency  to  bleed  on  slight  irritation, — so-called  spongi- 
ness  of  the  gums ;  4,  slight  tenderness  of  the  teeth  when  they  are 
snapped  together,  and  a  feeling  as  though  they  were  somewhat  longer 
than  they  should  be  ;  5,  a  metallic  taste  in  the  mouth. 

It  is  only  when  the  mouth  and  teeth  are  clean  that  these  symp- 
toms are  valuable  as  an  index  that  the  system  is  taking  all  the  mer- 
cury it  can  absorb  without  producing  marked  toxic  eifects.  When 
the  teeth  are  dirty,  caked  with  tartar,  decayed,  and  clogged  with 
masses  of  decomposing  organic  matter,  from  carelessness  in  the  use 
of  tooth-brush  and  tooth-washes,  or  from  neglect  in  seeking  the  aid 


THE   TKEATMENT   OF   SYPHILIS.  1013 

of  the  dentist,  salivation  will  occur  from  doses  of  mercury  far  below 
those  necessary  to  saturate  the  system  to  the  limit  of  safety.  Under 
such  circumstances  it  is  well  to  wait  until  the  mouth  has  received 
proper  attention  before  attempting  to  find  the  minimum  toxic  dose  of 
the  drug. 

When  one  or  all  of  these  symptoms  appear,  the  dose  should  be  re- 
duced at  once,  first  to  two-thirds,  later  to  one-half  that  dose,  if  the 
persistence  of  the  mouth  symptoms  indicates  further  reduction.  This 
is  the  standard  dose,  which  must  be  continued,  except  at  certain  in- 
tervals shortly  to  be  mentioned,  over  a  period  varying  from  two  to 
three  years.  If  during  this  time  there  is  an  outbreak  of  syphilis,  no 
matter  how  mild  or  insignificant,  the  dose  should  be  increased  to  the 
full  dose, — i.e.,  that  just  short  of  producing  ptyalism, — and  this  should 
be  continued  until  the  symptoms  vanish,  or  until  salivation  is  so  dis- 
tinctly threatening  that  diminution  of  the  dose  again  is  necessary. 

When  during  the  course  of  treatment  the  mucous  membrane  of 
the  mouth  becomes  sore  or  the  gums  boggy,  cleansing  or  antiseptic 
mouth-washes,  such  as  saturated  solution  of  potassium  chlorate,  alter- 
nating with  one  of  boric  acid,  listerine  and  water  equal  parts  of  each, 
or  phenol  sodique  one  part,  water  four  parts,  are  indicated;  such  mouth- 
washes have  a  prophylactic  influence  against  the  development  of  saliva- 
tion. Applications  of  a  four  per  cent,  solution  of  eucain  lactate  reheve 
the  pain  incident  to  eating.  Sweating,  vapor  baths,  laxatives  and  diu- 
retics are  indicated  as  means  favoring  the  elimination  of  mercury. 

The  weight  during  the  course  of  treatment  should  be  carefully 
noted.  This  should  be  taken  at  the  first  visit,  and  should  be  recorded 
subsequently  at  regular  intervals.  Stationary  or  increasing  weight  is 
favorable.  A  decrease  without  obvious  cause  should  occasion  grave 
apprehensions  as  to  the  subsequent  course  of  the  disease,  especially 
when  this  decrease  is  rapid  and  progressive. 

Under  the  course  of  treatment  just  described  there  is  usually 
steady,  often  rapid,  subsidence  of  all  symptoms.  Glandular  adeno- 
pathy diminishes,  and  often  disappears  completely,  though  there  may 
remain  traces  of  the  original  swelling ;  the  eruption  fades,  and  the 
agonizing  pains  and  high  temperature  which  sometimes  usher  in  the 
secondaries  subside  promptly. 

The  end  to  be  obtained  is  full  treatment  over  a  long  period.  By 
way  of  making  certain  that  a  proper  amount  of  mercury  is  being  ab- 
sorbed, the  internal  administration  of  the  drug  is  stopped  at  the  end 
of  six  weeks,  and  a  two  weeks'  course  of  inunction  in  equivalent  dose 
(one  scruple  to  two  drachms  of  mercurial  ointment  daily)  is  prescribed. 
The  reasons  for  this  are  that  absorption  from  the  digestive  tract  may 


3014  GENITO-URINAKY   DISEASES   AND   SYPHILIS. 

possibly  be  diminished  in  the  course  of  time,  and  that  an  interval  of 
rest  is  frequently  beneficial  to  that  tract.  After  two  weeks'  inunc- 
tion the  mouth  treatment  is  resumed. 

This  alternation  is  continued  for  a  period  of  two  years ;  that  is, 
during  this  time  there  are  six  months  of  inunction  and  eighteen 
months  of  internal  treatment. 

If  at  any  time,  however,  the  syphilitic  symptoms  persist  and  re- 
sist full  doses  by  the  mouth,  the  latter  are  withdrawn  and  inunctions 
are  substituted.  In  case  these  fail,  hypodermic  medication  is  re- 
sorted to. 

The  Systematic  Treatment  by  Iodides. — Potassium  iodide  is 
the  preparation  commonly  employed.  The  administration  of  this 
drug  is  indicated  at  the  end  of  the  second  year,  and  should  be  con- 
tinued for  six  months  in  combination  with  mercury,  constituting  the 
mixed  treatment.  No  marked  germicidal  effects  can  be  claimed  for 
the  iodides,  and  the  reason  for  their  use  is  based  on  clinical  rather 
than  theoretical  grounds.  It  is  quite  certain  that  their  usefulness  is 
not  due  to  an  influence  exerted  on  the  residue  of  a  prolonged  mer- 
curial course  by  virtue  of  which  that  residue  is  rendered  soluble  and 
potent.  Indeed,  there  is  evidence  that  the  administration  of  the 
iodides  actually  retards  the  elimination  of  mercury. 

In  the  early  stages  of  syphilis  they  are  of  little  value,  their  thera- 
peutic efficacy  increasing  in  direct  ratio  with  the  age  of  the  disease. 
The  commonly  accepted  theory  in  regard  to  their  action  is  that  they 
powerfully  stimulate  the  absorbent  system.  The  lesions  of  late  ter- 
tiary syphilis  are  particularly  characterized  by  excessive  cell-growth 
and  accumulation  of  imperfectly  organized  tissue,  made  up  for  the 
most  part  of  a  small  round-cell  infiltrate,  and  due  either  to  renewal  of 
activity  at  the  seat  of  former  disease,  or  to  a  crippling  or  obliteration  of 
lymphatics  incident  to  the  long-continued  hyperplasia  of  the  secondary 
stage.  The  clinical  proof  is  convincing  that  iodides  are  more  potent 
than  other  drugs  in  promoting  fatty  degeneration  and  absorption  of 
the  imperfectly  organized  exudates. 

The  iodides  may  be  satisfactorily  administered  in  sarsaparilla  as 
an  excipient,  not  because  this  exerts  any  marked  alterative  effect, 
but  rather  because  it  disguises  the  taste  of  the  drug.  The  following 
formula  may  be  employed  in  the  mixed  treatment : 


R  Hydrarg.  iodid.  rub. ,  gr.  iv  ; 
Potassii  iodidi,  ,^ss ; 
Syr.  sarsaparillse  comp.,  f,|vi. 
S. — Teaspoonful  in  three  ounces  of  water  four  times  daily. 


THE    TREATMENT   OF   SYPHILIS.  1015 

When  patients  object  to  taking  this  prescription,  the  iodide  may  be 
given  in  the  form  of  saturated  solution,  one  drop  of  which  represents 
approximately  one  grain. of  the  potassium  iodide: 

R   Potassii  iodidi,  ^v  ; 
Aquse,  q.  s.  ad  f,^i. 
S. — Five  to  ten  drops  three  times  a  day  in  half  a  glass  of  milk  or  water, 
increasing  the  number  of  drops  as  required. 

Or  the  iodide  may  be  given  in  the  form  of  compressed  tablets, 
mercury  being  administered  at  the  same  time,  as  previously  directed. 
Occasionally  other  combinations  of  iodine  are  better  tolerated  than 
the  potassium  salt,  and  in  certain  cases  a  combination  of  the  three 
best  known  salts  will  be  found  more  serviceable  than  any  one  admin- 
istered singly,  thus : 

li   Potassii  iodidi, 
Sodii  iodidi, 

Ammonii  iodidi,  aa  gr.  xcvi ; 
Syr.  aurantii  cort.,  f^i ; 
Aquse,  f^v. 
M.     S. — Teaspoonful,  freely  diluted,  four  times  daily. 

When  the  iodide  is  given  in  the  form  of  saturated  solution  the 
taste  may  be  almost  completely  disguised  by  dropping  the  required 
dose  in  a  glass  of  milk. 

When  it  disagrees  with  the  stomach, — and  this  is  often  the  case, — 
it  may  be  combined  with  essence  of  pepsin  in  the  proportion  of  five 
to  ten  grains  in  a  teaspoonful.  The  required  dose  of  this  mixture 
can  be  poured  in  half  a  glass  of  milk.  In  a  few  minutes  a  junket 
is  formed,  which  can  be  properly  seasoned,  and  which  completely 
conceals  the  disagreeable  taste  of  the  iodide.  Moreover,  when  admin- 
istered in  this  manner,  the  stomach  becomes  tolerant  to  a  remarkable 
degree.  The  most  important  practical  point  in  securing  the  fullest 
good  effects  of  the  iodides  with  the  least  harmful  results  is  to  give 
them  in  dilute  solution.  The  ordinary  dose  is  given  in  six  to  eight 
ounces  of  water,  and  is  soon  followed  by  another  tumblerful.  Hot 
water  still  further  facilitates  the  proper  absorption  of  the  drug. 
Iodides  should  be  given  about  an  hour  after  meals.  If  they  occasion 
griping  pains,  tannic  acid  may  be  added  to  the  prescription,  or  the 
following  formula  may  be  used  : 

B   Potassii  iodidi,  .^ss  ; 

Syr.  corticis  aurantii,  f^vi. 
M.     S. — A  teaspoonful  in  water  three  times  daily. 


1016  GENITO-URINAKY   DISEASES  AND   SYPHILIS. 

The  iodides  should  be  given  : 

1.  In  the  absence  of  symptoms,  at  the  expiration  of  a  two  years' 
course  of  mercury.  They  should  be  continued  for  six  months,  in  com- 
bination with  mercury  (mixed  treatment). 

2.  In  precocious  secondary  syphilis, — that  is,  when  the  lesions  re- 
semble in  type  those  of  the  tertiary  period,  affecting  the  fibrous  or 
connective  tissues,  the  bones,  the  nerve-centres,  and  important  vis- 
cera, or  when  they  appear  in  the  form  of  deep  ulcers  or  infiltrations 
of  the  skin, 

3.  In  all  forms  of  tertiary  syphilis. 

The  dose  of  the  iodides  is,  as  in  the  case  of  mercury,  greatly  in- 
fluenced by  individual  peculiarity.  Except  when  the  symptoms  are 
urgent  and  the  integrity  of  an  important  organ,  such  as  the  brain,  is 
threatened,  the  initial  dose  should  be  five  grains  three  times  a  day. 
This  should  be  increased  by  five  grains  every  third  day  until  the 
symptoms  for  which  the  drug  is  administered  have  disappeared,  or 
until  toxic  symptoms  denote  that  the  therapeutic  dosage  has  been 
passed.  In  the  case  of  the  iodides  the  production  of  the  toxic  symp- 
toms is  not  indicative  that  the  full  physiological  or  therapeutic  effects 
of  the  drug  have  been  obtained.  To  increase  the  iodides  until  the 
symptoms  are  relieved  sometimes  leads  to  the  administration  of  enor- 
mous doses,  but  the  evil  effects  of  these  are  usually  far  less  to  be 
dreaded  than  the  results  of  insufficiently  treated  syphilitic  lesions  of 
important  organs.  Thus  pushed,  the  iodides  frequently  cause  the  dis- 
appearance of  osteocopic  pains  and  motor  and  sensory  palsies,  and 
even  at  times  the  re-establishment  of  mental  faculties  after  they  have 
been  persistently  and  to  all  appearance  hopelessly  disordered.  In 
doubtful  cases  large  and  increasing  doses  may  be  administered  for 
diagnostic  purposes,  though  it  should  not  be  forgotten  that  conditions 
other  than  those  caused  by  syphilis  may  be  alleviated  or  cured  by  full 
doses  of  the  iodides,  thus  obscuring  the  value  of  the  therapeutic  test. 

The  alleged  value  of  tolerance  of  iodides  as  a  sign  of  syphilitic 
dyscrasia  is  without  foundation. 

Since  mercury  and  the  iodides  are  drugs  habitually  used  in  com- 
bating the  symptoms  of  syphiHs,  and  since,  if  injudiciously  adminis- 
tered, they  may  bring  about  conditions  even  worse  than  those  for  the 
cure  of  which  they  are  given,  the  toxic  symptoms  which  they  occasion 
must  be  carefully  considered. 

The  Toxic  Effects  of  Mercury. — Hydrargyrism. — Hydrar- 
gyrism  may  be  either  acute  or  chronic.  The  symptoms  of  either  of 
these  conditions  may  be  occasioned  by  the  introduction  of  mercury 
into  the  system,  whether  it  be  by  way  of  the  alimentary  tract,  through 


THE   TKEATMENT   OF   SYPHILIS.  1017 

the  skin,  as  when  the  drug  is  administered  by  inunction,  vaporization, 
or  baths,  or  through  the  muscles  and  subcutaneous  tissue,  as  when 
preparations  of  mercury  are  administered  hypodermically.  It  should 
be  borne  in  mind  that  lesions  of  the  kidney  particularly  predispose  to 
the  development  of  hydrargyrism. 

Acute  Hydrargyrism. — The  mild  form  of  acute  hydrargyrism  is 
that  already  described,  and  on  its  appearance  is  based  the  dosage 
of  mercury  during  the  secondary  period.  The  symptoms  are  a  slight 
ropiness  or  stringiness  of  the  saliva,  with  increase  in  its  quantity. 
During  the  night  there  is  some  flow  from  the  corners  of  the  mouth. 
The  gums  are  slightly  congested,  and  bleed  readily  when  touched. 
This  is  especially  noticed  about  the  posterior  molars  when  the  teeth 
are  healthy,  but  is  frequently  observed  at  the  roots  of  the  lower  in- 
cisors, since  here  tartar  is  prone  to  collect,  and  hence  the  mucous 
membrane  is  more  vulnerable.  When  the  teeth  are  snapped  together, 
slight  tenderness  will  be  noticed.  Close  upon  these  symptoms,  often 
preceding  them,  come  distinct  metallic  taste  in  the  mouth  and  fetor 
of  the  breath. 

If  the  drug  is  continued  after  these  symptoms  develop,  and  in 
some  cases  even  though  its  ingestion  be  stopped  at  once,  evidences 
of  salivation  become  even  more  pronounced.  The  gums  are  greatly 
swollen  and  ulcerated.  The  teeth  are  loosened,  the  tongue — indeed, 
the  whole  mucous  membrane  of  the  mouth — becomes  oedematous  and 
congested,  and  erosions  and  ulcers  appear  upon  its  surface.  There  is 
an  enormously  increased  flow  of  saliva,  the  submaxillary  and  parotid 
glands  are  swollen,  cracks  and  ulcers  appear  at  the  corners  of  the 
mouth,  and  the  breath  is  indescribably  foul.  In  marked  cases  the 
patient  is  unable  to  masticate,  to  swallow,  or  even  to  speak,  and  the 
strength  fails  rapidly. 

In  some  instances  hydrargyrism  expends  its  violence  upon  the  ali- 
mentary canal  and  the  kidneys,  producing  colicky,  bloody  stools,  and 
albuminuria.  This  form  of  poisoning  is,  however,  rare,  save  when 
the  hypodermic  method  is  employed. 

Very  exceptionally  acute  mercurialization  appears  in  the  form  of 
skin  eruption.  This  develops  as  an  erythema,  a  dermatitis,  or  an 
eczema  rubrum,  and  is  always  an  expression  of  idiosyncrasy. 

Chronic  Hydrargyrism. — In  certain  cases  the  administration  of 
mercury  seems  to  produce  a  chronic  catarrh  of  the  gastro-intestinal 
mucous  membrane.  The  patient  suffers  from  the  characteristic 
symptoms  of  this  condition,  the  appetite  fails,  emaciation  is  progres- 
sive, albuminuria  may  appear,  and  there  is  complaint  of  great  mus- 
cular weakness.     A  profound  gloom  seizes  upon  the  patient,  or  he 


1018  GENITO-UEINAET   DISEASES   AND  SYPHILIS. 

becomes  nervous  and  hysterical.  Since  absolutely  identical  symp- 
toms may  be  produced  by  the  disease  for  the  cure  of  which  mercury 
is  given,  the  determination  of  the  cause  of  such  symptoms  is  very 
important. 

When  mercury  has  been  administered  in  comparatively  full  doses 
for  a  long  time,  and  when  such  symptoms  develop  and  are  progressive, 
it  is  wise  to  discontinue  the  specific  drug  and  to  devote  particular  at- 
tention to  diet,  hygiene,  and  medication  suited  to  the  cure  of  the 
gastro-intestinal  catarrh.  The  improvement  following  such  a  course 
of  treatment  forms  the  best  index  to  the  etiology  of  the  symptoms, 
though  this  improvement  is  always  slow. 

When  such  symptoms  develop  in  cases  which  have  been  treated 
by  insufficient  doses  of  mercury  it  may  be  assumed  that  they  are  the 
effects  of  syphilis,  and  that  on  pushing  the  drug  they  will  probably 
disappear.  Albuminuria  may  be  due  to  mercury  or  to  the  action  of 
syphilis.     The  cause  can  be  determined  only  by  the  therapeutic  test. 

The  effects  of  an  overdose  of  mercury  on  the  nervous  system  are 
thought  by  some  writers  to  be  as  difficult  to  distinguish  from  those 
of  syphilis  as  are  the  symptoms  in  connection  with  the  gastro-intes- 
tinal tract  and  the  kidneys.  Hydrargyrism  is  said  to  produce  trem- 
bhngs,  attacks  resembling  epilepsy  or  apoplexy,  cerebral  palsies  and 
anaesthesias,  cephalalgias  and  arthralgias,  disturbances  of  sleep,  ver- 
tigo, and  dementia.  These  symptoms  are  chronic  in  type,  and  yield 
slowly  on  cessation  of  treatment.  Fortunately,  they  are  exceedingly 
uncommon.     We  have  rarely  seen  any  of  them. 

Treatment — Salivation  is  best  avoided  by  minute  attention  to  the 
hygiene  of  the  mouth  and  by  frequent  inspection  of  the  patient,  so 
that  the  drug  may  be  stopped  or  its  dosage  diminished  on  the  develop- 
ment of  the  first  symptoms.  When  patients  cannot  be  kept  under 
observation  they  should  be  told  the  symptoms  of  beginning  ptyaHsm, 
and  should  be  instructed  properly  to  regulate  the  dose  in  the  event 
of  such  symptoms  developing.  When  ptyalism  has  developed,  potas- 
sium chlorate  and  atropine  are  the  most  efficient  remedies.  In  con- 
junction with  an  astringent  mouth-wash,  used  frequently,  the  patient 
is  given  daily  hot,  sweating  baths,  the  bowels  are  opened  freely,  and 
the  kidneys  are  encouraged  to  act  by  copious  draughts  of  water. 

Potassium  chlorate  is  administered  in  the  form  of  a  saturated 
aqueous  solution.  A  teaspoonful  of  the  salt  is  added  to  a  glass  of 
water,  and  the  patient  is  instructed  to  rinse  his  mouth  with  this  mix- 
ture every  few  minutes. 

In  alternation  with  this  a  disinfectant  and  astringent  lotion  may  be 
employed,  such  as — 


THE   TREATMENT   OF   SYPHILIS.  1019 

R  Acid,  boric, 

Acid,  tannic,  aa  Qiv; 

Mel.  rosae,  f^ii ; 

Aquae,  q.  s.  ad  f^vi. 
M.     S. — Use  as  a  mouth-wash. 

Atropine  should  be  given  in  small  doses,  frequently  repeated,  until 
some  effect  upon  the  pupil  is  noted.  The  drug  may  be  administered 
in  powder  form,  dropped  on  the  tongue,  and  allowed  to  dissolve. 

R   Atropinae  sulphat.,  gr.  3^^; 

Sacch.  lactis,  q.  s. 
M.  et  ft.  chart,  no.  x. 
S. — One  powder  every  three  or  four  hours. 

In  severe  forms  of  salivation  ulcerated  and  eroded  patches  should 
be  touched  with  five  to  ten  per  cent,  solution  of  silver  nitrate,  and 
more  powerful  antiseptics  should  be  employed,  as,  for  instance,  hydro- 
gen peroxide  in  spray  form,  phenol  sodique,  or  potassium  perman- 
ganate 1  to  1000. 

The  pain  incident  to  taking  food  may  be  allayed  by  painting  the 
gums  and  eroded  patches  with  a  three  per  cent,  solution  of  cocaine 
just  before  eating. 

The  elimination  of  mercury  from  the  system  is  materially  hastened 
by  prolonged  hot-air  or  vapor  baths,  and  by  the  administration  of 
diaphoretics,  diuretics,  and  laxatives. 

If  the  diagnosis  of  chronic  hydrargyrism  is  assured,  withdrawal  of 
the  drug  and  the  inauguration  of  a  tonic  and  stimulating  course  of 
treatment  are  indicated.  Change  of  air  and  surroundings  is  particu- 
larly serviceable,  especially  when  reinforced  by  scrupulous  attention 
to  hygiene  and  a  carefully  selected  ferruginous  tonic.  In  case  mer- 
cury is  subsequently  indicated,  it  should  not  be  administered  by  the 
mouth. 

The  Toxic  Effects  of  the  Iodides. — lodism. — Under  the  general 
heading  iodism  are  included  the  various  toxic  symptoms  which  may  de- 
velop in  consequence  of  over-dosage  with  this  drug.  Those  commonly 
observed  are  gastro-intestinal  irritation,  coryza,  pustular  skin  erup- 
tion, lachrymation,  tinnitus  aurium,  and  mental  depression.  Excep- 
tionally neuritis  and  acute  oedema  of  the  larynx  are  occasioned  by 
comparatively  mild  doses  of  the  iodides. 

As  in  the  case  of  mercury,  iodides  are  most  prone  to  produce  un- 
toward effects  in  those  suffering  from  kidney  degeneration. 

The  lesions  of  the  iodide  dermatoses  may  simulate  almost  any  of 
the  recognized  forms  of  acute  cutaneous  eruption.     They  commonly 


1020  GENITO-UKINAEY   DISEASES  AND  SYPHILIS. 

appear  in  the  form  of  acne,  but  erythema,  eczema,  and  herpes  are  by- 
no  means  rare.  Purpura  is  frequently  observed,  and  even  sloughing, 
gangrenous  ulcers  are  occasionally  noted. 

These  eruptions  are  due  to  idiosyncrasy  and  bear  no  definite  rela- 
tion to  the  dose  employed.  In  some  instances  small  doses  produce 
toxic  effects ;  in  others  heroic  doses  are  taken  with  impunity. 

In  the  dose  ordinarily  employed  in  the  treatment  of  syphilis  a 
large  proportion  of  patients  will  exhibit  no  symptoms  whatever  from 
the  use  of  the  iodides.  A  larger  proportion  will  be  troubled  with  a 
coppery  taste  in  the  mouth  and  with  an  acneiform  eruption,  affect- 
ing the  face  by  preference,  but  often  widely  distributed.  Coryza, 
lachrymation,  slight  conjunctivitis,  and  symptoms  of  indigestion  inci- 
dent to  gastro-intestinal  catarrh  are  also  common.  A  very  small 
percentage  of  the  cases  will  suffer  from  swelhng  of  the  mucous  mem- 
brane of  the  larynx  and  pharynx,  sometimes  so  great  as  to  endanger 
hfe,  and  from  an  especially  severe  skin  eruption  much  like  furuncu- 
losis,  which  may  go  on  to  the  purpuric  or  the  sloughing  form. 

Treatment — The  treatment  of  iodism  depends  upon  the  severity 
of  the  symptoms.  In  the  milder  cases,  and  particularly  when  it  is 
important  to  continue  administering  the  drug  for  the  purpose  of  effect- 
ing resolution  and  absorption  of  syphilitic  deposits,  the  iodide  may  be 
continued,  or  the  dose  may  be  slightly  increased,  since  in  most  cases 
tolerance  is  established  and  the  coryza  and  eruption  disappear.  A  few 
drops  of  Fowler's  solution  may  be  administered  together  with  the 
iodides.  The  gastro-intestinal  symptoms  are  controlled  by  carefully 
regulating  the  diet,  administering  slightly  astringent  and  antiseptic 
digestive  powders,  and  giving  the  iodides  largely  diluted,  preferably 
in  milk  to  which  essence  of  pepsin  has  been  added.  Or,  if  this 
method  is  not  feasible,  each  dose  of  the  drug  should  be  dissolved  in  a 
full  glass  of  soda-water,  flaxseed  tea,  or  other  bland  excipient.  The 
tolerance  of  iodides  is  by  no  means  indicative  of  the  syphilitic  diath- 
esis, nor  is  extreme  sensitiveness  to  the  drug  the  slightest  index  as  to 
the  absence  of  the  disease. 

METHODS   OF   GIVING  MERCURY. 

Aside  from  the  dose,  which  must  always  depend  on  individual  sus- 
ceptibility, there  are  certain  definite  methods  for  administering  mer- 
cury. These  are  (1)  by  mouth  administration  ;  (2)  by  inunction  ;  (3) 
by  hypodermic  injection  ;  (4)  by  vaporization  ;  (5)  by  mercury  baths. 

Mouth  Administration. — The  method  of  administering  mer- 
cury by  the  mouth  and  the  choice  of  preparations  have  already  been 
indicated., 


THE   TREATMENT   OF   SYPHILIS.  1021 

Though  protiodide,  gray  powder,  and  bichloride  of  mercury  in 
varying  doses  and  vehicles  are  the  most  valuable  drugs  for  adminis- 
tration by  the  mouth,  there  are  other  combinations  of  mercury  which 
have  received  such  high  professional  endorsement  that  mention  of 
them  is  not  out  of  place. 

The  tannate  of  mercury,  recommended  particularly  by  Allen, 
Petrini,  Schwimmer,  and  Lustgarten,  is  of  value,  according  to  this 
last  author,  because  it  passes  through  the  stomach  without  being 
acted  upon  by  the  acids  therein  contained,  and  when  it  reaches  the 
duodenum  is  converted  by  the  alkaline  juices  of  this  portion  of  the 
intestine  into  minute  metallic  globules,  which  are  readily  absorbed. 
The  drug  is  administered  in  doses  of  a  grain  three  to  five  times  daily, 
some  simple  bitter,  such  as  extract  of  gentian,  being  employed  as  an 
excipient.     The  following  formula  may  be  ordered : 

B  Hydrarg.  tannici  oxydulat.,  gr.  iss ; 

Acid,  tannici, 

Sacch.  lact.,  aa  gr.  |. 
M.  et  ft.  in  pulv.  no.  i. 
S. — One  powder  twice  or  three  times  daily. 

Or  tannate  of  mercury  may  be  given  in  the  form  of  compressed 
tablets,  each  to  contain  one  grain. 

The  succinimide  of  mercury  has  been  recommended  by  Jullien. 
This  is  administered  in  pill  form  in  doses  of  one-third  to  one-half 
grain  daily.  It  is  said  to  cause  no  gastric  symptoms  and  not  to 
salivate. 

Calomel  is  frequently  employed,  as  in  the  following  prescription : 

R   Hydrarg.  chlor.  mit.,  gr.  v ; 

Sacch.  lact.,  .^ss. 
M.  et  in  chart,  no.  x  div. 
S. — One  powder  after  each  meal. 

Carbolate  of  mercury  has  been  used  in  doses  of  one-third  of  a 
grain  two  to  six  times  daily. 

SaHcylate  of  mercury  is  warmly  commended  as  possessing  high 
antiseptic  powers,  due  to  the  fact  that  it  represents  a  combination  of 
two  germicidal  drugs.     The  dose  is  the  same  as  for  yellow  iodide. 

Red  iodide  of  mercury,  particularly  in  combination  with  ipecac, 
administered  in  the  form  of  tablets,  will,  according  to  Curtis,  produce 
the  constitutional  influence  of  mercury  without  unpleasantly  affecting 
the  mucous  membranes.  One-eighth  of  a  grain  of  ipecac  with  one- 
sixteenth  of  a  grain  of  red  iodide  may  be  given  ten  to  twelve  times 
daily  without  producing  gastric  or  enteric  symptoms. 


1022  GENITO-URINARY   DISEASES   AND   SYPHILIS. 

Zittmann's  decoction  is  an  elaborate  preparation,  containing  sarsa- 
parilla,  calomel,  cinnabar,  alum,  anise-  and  fennel-seeds,  senna  leaves, 
and  liquorice  root.  The  special  virtue  of  this  decoction  is  incident  to 
the  elimination  produced  by  diaphoresis  and  purgation.  For  details 
and  technique  of  its  administration,  see  page  1042. 

Blue  mass  is  a  favorite  with  many  syphilographers.  The  best 
combinations  of  this  drug  are  as  follows  (Bumstead) : 

B    Mass.  hydrarg. ,  9ii ; 

Ferri  sulph.  exsiccat.,  Qi; 

Ext.  opii,  gr.  v. 
M.  et  in  pil.  no.  xx  div. 
S. — One  pill  from  two  to  four  times  daily. 

R    Mass.  hydrarg.,  Qi ; 

Hydrarg.  chlorid.  mit.,  Bss; 

Hydrarg.  cum  creta,  Qii ; 

Ext.  opii,  gr.  v. 
M.  et  in  pil.  no.  xx  div. 
S. — -From  two  to  four  pills  daily. 

The  last  prescription  is  ordered  when  a  rapid  constitutional  effect 
is  desired. 

Inunctions  are  strongly  advised  by  many  syphilographers  as 
representing  the  best  method  of  administering  mercury  in  the  routine 
treatment  of  syphilis.  The  objections  to  this  mode  are  its  uncleanli- 
ness,  the  skin  irritation  which  it  is  liable  to  excite,  and  perhaps  chiefly 
the  difficulty  of  applying  it  without  exposing  the  patient  to  the  risk 
of  having  it  known  that  he  is  being  treated  for  syphilis.  Usually, 
however,  a  representation  of  the  great  advantage  of  this  method  as 
regards  the  attainment  of  permanent  cure,  and  especially  in  relation 
to  the  disappearance  of  existing  symptoms,  will  insure  the  co-operation 
of  intelligent  patients. 

The  testimony  as  to  the  value  of  inunctions  is  overwhelming.  In 
all  the  most  successful  centres  for  the  cure  of  syphilis  inunction  is 
practically  the  chief  mode  of  administering  mercury.  This  method 
has  for  years  been  the  mainstay  for  the  subduing  of  violent  outbreaks 
which  do  not  yield  to  the  mouth  treatment.  After  seeing  the  striking 
results  consequent  on  its  employment  in  what  might  be  called  the 
emergency  treatment,  the  transition  from  its  occasional  to  its  habitual 
use  in  the  routine  conduct  of  syphilis  is  easy  and  natural. 

Whether  inunctions  are  employed  for  the  relief  of  sudden  out- 
break, or,  as  has  been  recommended,  as  a  means  of  administering 
mercury  in  the  intervals  of  treatment  by  the  mouth,  the  general 
hygienic  conduct  of  life  should  be  as  rigidly  ordered  as  when  the  drug 


THE   TREATMENT   OF   SYPHILIS.  1023 

is  given  in  pill  form  ;  i.e.,  the  mouth  should  be  put  in  perfect  order, 
the  condition  of  the  stomach  attended  to,  etc. 

In  prescribing  inunctions  the  patient  is  ordered  a  mixture  of  equal 
parts  of  mercurial  ointment  and  carbolized  cosmoline.  Lanolin  as 
an  excipient  is  too  gummy,  and  lard  speedily  becomes  rancid.  The 
undiluted  ointment  is  too  irritating,  and  the  oleate  is  unsatisfactory  in 
its  results. 

The  prescription  may  be  written  as  follows : 

R    Unguent,  hydrarg., 

Unguent,  petrolei  cai'bolat. ,  aa  §i. 
M.  et  in  part.  no.  viii  div. 
S. — Use  one  portion  at  bedtime. 

Each  dose  may  be  enclosed  in  a  compressible  gelatin  capsule  or  in 
a  cachet  of  stiff  paper.  The  bulk  of  this  prescription  may  be  some- 
what reduced  by  using  the  pure  mercurial  ointment  put  up  in  cachets 
and  instructing  the  patient  before  using  the  ointment  to  anoint  with 
carbolated  cosmoline  the  surface  which  is  to  be  utilized. 

The  dose  of  mercurial  ointment  for  the  ordinary  healthy  adult  is 
from  twenty  grains  to  a  drachm  daily ;  this  can  be  tolerated  for  from 
two  to  three  weeks.  If  it  is  long  continued  without  interruption, 
stomatitis  or  dermatitis  is  liable  to  develop. 

The  dose  of  ointment  having  been  settled  upon,  the  patient  is  in- 
structed as  to  its  application.  He  should  provide  himself  with  woohen 
underclothing  of  a  thickness  suitable  to  the  time  of  year  and  of  such 
quality  or  condition  that  no  great  loss  will  be  suffered  from  its  being 
permanently  stained.  This  set  of  underclothing  should  be  w^orn  for 
from  three  days  to  a  week  without  being  changed. 

Whenever  practicable,  he  should  do  his  own  rubbing,  and  before 
the  first  dose  should  take  a  somewhat  prolonged  hot  bath.  He 
should  after  his  bath  and  immediately  before  retiring  occupy  fully 
twenty  minutes  in  rubbing  in  the  amount  of  ointment  prescribed  for 
one  treatment. 

Since  this  ointment  irritates  the  skin  if  its  application  is  too  fre- 
quently repeated  in  one  place,  different  surfaces  are  selected  on  suc- 
cessive nights.  These  surfaces  should  be  comparatively  hairless  and 
fairly  accessible.  The  regions  of  preference  are  the  inner  surfaces  of 
the  thighs,  the  antero-internal  surfaces  of  the  arms  and  forearms,  the 
sides  of  the  thorax,  the  flanks,  and  the  antero-lateral  surfaces  of  the 
abdomen ;  sometimes  the  buttocks  and  the  soles  and  inner  surfaces 
of  the  foot.  When  the  nurse  does  the  rubbing  the  whole  back  may 
be  included.     By  passing  from  one  to  the  other  of  these  regions  in  a 

65 


1024  GENITO-URINAEY   DISEASES   AND  SYPHILIS. 

definite  order  no  one  of  them  need  be  used  oftener  than  once  a  week, 
thus  giving  plenty  of  time  for  the  subsidence  of  any  slight  irritation 
which  the  inunction  may  occasion. 

If  there  is  marked  skin  irritation  in  any  particular  locality,  this 
whole  region  is  carefully  washed  with  soap  and  hot  water  and  the 
folio  vving  ointment  is  applied  : 


R   Hydrarg.  chlorid.  mit.,  gii ; 

Unguent,  zinci  oxidi, 

Unguent,  petrolei  carbolat.,  aa  ^ss. 
M.  et  ft.  unguent. 


Or,  if  there  is  no  indication  for  a  mild  mercurial  influence,  such  as 
would  be  exerted  by  this  mixture,  the  irritated  surface  is  cleansed, 
dried,  and  dusted  with  a  mixture  of  starch  and  bismuth.  Inunctions 
are  taken  before  going  to  bed  simply  as  a  matter  of  convenience  ;  they 
may  be  given  at  any  time  during  the  twenty-four  hours. 

Under  the  routine  treatment  of  syphilis  already  described  this 
method  is  enforced  for  two  weeks  at  a  time  once  in  every  two 
months.  It  may  be  kept  up  longer  when  indicated,  and  should  cer- 
tainly be  continued  in  the  presence  of  relapsing  syphilides  of  the  skin 
or  mucous  membranes,  or  in  cases  in  which  the  viscera  are  threat- 
ened. In  the  ordinary  benign  cases  of  syphilis,  however,  it  is  not 
necessary  to  employ  this  or  any  other  troublesome,  tiresome,  or 
painful  treatment  to  the  exclusion  of  the  administration  of  mercury 
by  the  mouth. 

The  portion  of  this  treatment  which  will  be  most  seriously  objec- 
tionable to  fastidious  patients  is  the  continued  wearing  of  soiled  under- 
clothing and  the  avoidance  of  the  regular  morning  bath.  Neither  of 
these  conditions  is  essential  to  the  successful  inunction  treatment. 
The  patient  may  be  directed  to  wear  the  same  underclothing  only  at 
night,  and  may  be  allowed  his  bath,  the  residue  of  the  ointment  read- 
ily coming  away  under  the  use  of  soap  or  hot  water.  He  can  then 
put  on  clean  underclothes  for  the  day,  resuming  at  night  after  his  next 
rubbing  the  undergarments  already  soiled  by  the  ointment.  The  con- 
tinued surface  application  of  that  portion  of  the  ointment  remaining 
after  all  has  been  rubbed  in  that  the  skin  will  receive  seems  to  be  an 
important  feature  in  bringing  about  full  absorption. 

It  is  undoubtedly  true  that  some  persons  exhibit  an  idiosyncrasy 
against  inunctions,  eczematous  eruptions  appearing  over  the  entire 
body,  and  in  the  blonde  and  thin-skinned  the  local  irritation  is  some- 
times so, great  that  this  method  of  treatment  is  not  applicable. 


THE   TKEATMENT   OF   SYPHILIS.  1025 

In  place  of  ointments  mereurial  soaps  have  been  advised.  These 
are,  however,  more  uncertain  in  their  effects  and  less  accurate  in 
their  composition  than  ointments,  and,  although  cleaner,  require  more 
time  in  their  application.  Schuster  employs  a  soap  commended  by 
Charcot,  which  is  made  of  equal  parts  of  mercury,  mutton  suet,  and 
potash  soap.  These  ingredients  are  gently  heated,  and  to  them  is 
added  enough  potassium  hydrate  to  produce  saponification.  This 
mixture  is  rubbed  into  the  skin  for  from  fifteen  to  twenty  minutes 
exactly  as  is  mercurial  ointment. 

Mercury  plasters  have  also  been  proposed,  but  have  as  yet  re- 
ceived scanty  recognition,  Chassaignac  employed  the  emplastrum 
de  Vigo  cum  mercurio,  which  contains  metallic  mercury  triturated 
with  styrax  and  turpentine  and  added  to  ordinary  lead  plaster. 
Quinquaud  obtained  excellent  results  from  a  calomel  plaster  made 
by  suspending  1000  parts  of  calomel  in  300  parts  of  castor  oil  and 
adding  3000  parts  of  melted  diachylon  plaster.  This  mixture  is 
spread  on  linen,  is  applied  to  the  skin,  and  is  kept  on  for  eight  days. 
The  plaster  should  be  about  sixteen  inches  square,  and  should  con- 
tain about  three  drachms  of  calomel. 

Hypodermic  Injections. — The  specific  claims  made  for  this 
treatment  are  as  follows:  (1)  A  precise  dosage  is  obtainable;  (2)  it 
saves  time  and  labor  on  the  part  of  both  physician  and  patient, 
visits  being  rendered  infrequent ;  (3)  it  necessitates  little  change  of 
diet  or  of  habits  of  life ;  (4)  the  patient's  skin  and  digestive  organs 
remain  unaffected,  except  in  rare  instances  ;  stomatitis  is  exceptional ; 
(5)  the  disease  is  readily  concealed;  (6)  there  is  lessened  expense; 
(7)  permanent  cure  is  accomphshed  in  a  short  time  and  with  a 
minute  amount  of  mercury  ;  (8)  a  powerful  influence  is  exerted  more 
readily  and  surely  in  l^he  presence  of  grave  and  threatening  visceral 
troubles  ;  (9)  the  time  required  for  a  therapeutic  diagnosis  is  shortened 
in  doubtful  cases. 

Of  these  various  claims  the  one  of  most  importance  is  that  the 
disease  is  permanently  cured  in  a  short  time.  As  to  this  point  there 
is  yet  no  conclusive  evidence. 

The  prompter  effect  of  hypodermic  medication  in  cases  of  serious 
visceral  troubles  may  be  doubted,  as  may  also  the  claim  in  favor  of 
the  skin  and  digestive  organs  remaining  unaffected.  It  may  be  fairly 
questioned  whether  absorption  from  the  subcutaneous  tissues  is  sub- 
ject to  markedly  less  variation  than  that  from  the  gastro-intestinal 
raucous  membrane.  The  other  claims  as  to  the  value  of  this  method 
are  unimportant. 

The  disadvantages  of  the  method  are:  (1)  It  is  often  extremely 


1026  GENITO-UKINAKY  DISEASES   AND   SYPHILIS. 

painful,  and  is  strongly  objected  to  by  many  patients ;  (2)  it  is  some- 
times followed  by  dangerous  and  even  rapidly  fatal  toxic  symptoms ; 
(3)  it  has  local  sequelae,  such  as  erythema,  cellulitis,  abscess,  and 
sloughing ;  (4)  it  is  a  treatment  which  cannot  be  carried  out  by  the 
patient  himself,  but  usually  requires  frequent  intervention  on  the 
part  of  the  surgeon. 

It  would  seem  fairly  clear  that  the  disadvantages  of  hypodermic 
medication  as  a  routine  treatment  more  than  counterbalance  the  still 
unproved  advantages,  and  that  it  should  be  reserved  for  certain 
exceptional  cases  shortly  to  be  mentioned. 

The  drugs  employed  in  the  hypodermic  method  of  treatment  are 
either  soluble  or  insoluble.  In  each  class  there  are  many  prepa- 
rations. The  two  most  widely  used  are  corrosive  sublimate  and 
calomel. 

The  technique  of  the  injections  is  practically  the  same,  independent 
of  the  form  of  mercury  employed.  The  solution  or  the  emulsion 
must  be  steriHzed,  and  the  surface  beneath  which  the  injection  is  to 
be  driven,  the  syringe,  and  the  hands  of  the  surgeon  must  receive  the 
same  preparation  as  though  a  formal  operation  were  to  be  performed. 
The  needle  should  be  boiled  and  the  syringe  should  be  washed  in 
boihng  water  and  be  soaked  in  1  to  20  carboHc  solution.  For  most 
of  the  preparations  the  ordinary  hypodermic  syringe  with  a  large 
needle  will  answer. 

Since  there  are  reasons  for  believing  that  the  local  influence  of 
mercury  is  of  great  advantage,  the  existence  of  a  serious  lesion  in  an 
accessible  locahty  may  occasionally  determine  the  site  of  injection. 
In  the  absence  of  such  lesion  the  injections  are  usually  driven  into 
the  upper  dorsal  or  the  post-trochanteric  region,  since  these  are  not 
subject  to  pressure  or  to  the  observation  of  others,  and  are  not  spe- 
cially sensitive.  Moreover,  they  are  covered  by  a  thick  layer  of  sub- 
cutaneous tissue.  It  is  into  this  rather  than  the  muscular  tissue  that 
the  injection  should  be  driven,  since,  if  abscess  occur,  it  is  much  more 
readily  managed  when  superflcial  than  when  subfascial. 

The  method  of  throwing  in  the  fluid  is  hke  that  employed  in 
ordinary  injections,  except  that  special  precautions  are  taken  against 
driving  insoluble  preparations  into  a  vein,  since  they  will  probably 
give  rise  to  pulmonary  emboK.  This  has,  indeed,  occurred  in  a  num- 
ber of  cases.  To  avoid  this  accident,  the  needle  is  first  thrust  in, 
disconnected  from  the  syringe,  and  is  allowed  to  remain  for  a  moment, 
to  see  if  any  blood  flows  through  its  canal ;  in  the  absence  of  this  the 
injection  is  driven  in.  The  puncture  points  are  covered,  on  with- 
drawal of  the  needle,  by  the  clean  finger  of  the  operator,  and  are 


THE    TREATMENT  OF  SYPHILIS.  1027 

dressed  with  iodoform  collodion.  Unless  the  fluid  used  is  aseptic, 
cellulitis  or  abscess  will  develop. 

Most  careful  antiseptic  precautions  may  not  prevent  microbic 
infection,  this  possibly  coming  from  the  deeper  layers  of  the  skin. 

The  pain  incident  to  these  injections  varies  greatly.  Occasionally 
it  lasts  for  hours  or  even  days,  and  is  usually  more  severe  with  the 
insoluble  salts  of  mercury.  Tenderness  persists  for  some  time,  and 
may  be  so  great  as  to  occasion  almost  complete  disability. 

When  a  soluble  preparation — and  the  best  is  corrosive  sublimate — 
is  employed,  the  dose  is  from  one-twelfth  to  one-third  of  a  grain  dis- 
solved in  about  twenty  drops  of  distilled  water.  A  hypodermic  con- 
taining this  quantity  of  the  drug  may  be  administered  daily  or  every 
second  day  until  premonitory  symptoms  of  stomatitis  appear.  It  may 
then  be  given  at  longer  intervals.  When  on  account  of  its  situa- 
tion an  outbreak  of  syphilis  becomes  dangerous,  as  in  the  brain,  and 
prompt  action  is  imperative,  larger  doses  may  be  injected. 

Sublimate  injections  are  specially  indicated  when  mercury  admin- 
istered by  the  mouth  occasions  gastro-intestinal  irritation  or  other  un- 
toward symptoms,  and  when  given  by  inunctions  it  causes  dermatitis. 
These  injections  are  also  indicated  when  syphilitic  lesions  are  devel- 
oping in  spite  of  ordinary  treatment,  when  syphilomata  are  particu- 
larly obstinate,  and  when,  in  certain  cases,  on  account  of  intercurrent 
disease,  it  is  necessary  to  utilize  the  stomach  for  the  administration 
of  other  drugs.     The  favorite  formula  is  the  following : 

B   Hydrarg.  chlor.  corros.,  gr.  4^; 
Sodii  chlor.,  gr.  iiiss ; 
Aquae  destil.,  f^i. 
S. — One   per  cent,  solution  of  corrosive  mercuric  chloride.     Ten  to  thirty 
minims  hypodermically. 

This  solution  can  be  modified  by  increasing  or  diminishing  the 
quantity  of  corrosive  chloride,  a  five  per  cent,  solution  being  advocated 
by  Lukasiewicz. 

Finger  employs  a  one  per  cent,  sublimate  solution  containing 
twenty  per  cent,  of  common  salt. 

The  succinimide  of  mercury,  the  albuminate,  the  iodo-tannate, 
the  carbolate,  the  formamide,  the  benzoate,  and  other  salts  have  been 
warmly  commended  by  individual  observers. 

Of  the  insoluble  salts  administered  hypodermically,  calomel  is  the 
type.  This  is  given  in  doses  of  one-half  to  one  grain  every  four  days., 
two  grains  weekly,  or  three  grains  every  ten  or  twelve  days.  The 
following  formulae  may  be  employed : 


1028  GENITO-UKINAKY   DISEASES   AND   SYPHILIS. 

Be   Hydrarg.  chlor.  mit.,  gr.  ss ; 

Glycerin,  purificat.,  gtt.  x  ; 

Aquae  destil.,  gtt.  x. 
M.     S. — Use  as  an  injection. 

R  Hydrarg.  clalor.  rait., 
Sodii  chloridi,  aa  gr.  i ; 
Aquae  destil.,  gtt.  xxx. 

The  method  of  using  calomel  as  formulated  by  Besnier  in  the 
Hospital  St.  Louis  is  as  follows : 

R   Calomel,  1  part; 
Vaseline,  20  parts. 

The  drug  is  suspended  in  the  excipient  as  perfectly  as  possible. 
The  mixture  is  boiled  before  being  used,  and  the  hands  of  the  oper- 
ator, the  surface  into  which  the  injection  is  to  be  driven,  and  the 
syringe,  are  sterilized.  The  region  of  the  buttocks  is  that  of  pref- 
erence. The  needle  should  be  an  inch  in  length,  and  should  be  driven 
vertically  into  the  tissues  down  to  the  guard  by  one  quick  thrust.  It 
should  be  observed  for  a  moment  to  see  if  any  blood  flows  from  it, 
and,  if  not,  the  syringe  should  be  attached  and  the  injection  driven  in 
slowly. 

There  is  nearly  always  marked  pain,  sometimes  lasting  for  hours 
or  days,  and  this  is  followed  by  distinct  inflammatory  reaction  and 
the  formation  of  a  hard,  painful  nodule,  which  lasts  for  two  or  three 
weeks. 

Severe  stomatitis  is  not  infrequently  observed ;  this  may  pro- 
gressively grow  worse,  and  in  such  a  case  would  indicate  the  excision 
of  the  focus  into  which  calomel  has  been  injected.  Fatal  gastro- 
enteritis has  been  noted,  and  embolic  pneumonia  has  developed  in 
consequence  of  the  calomel  having  been  driven  into  a  vein. 

As  opposed  to  these  evil  effects,  calomel  thus  administered  exer- 
cises a  prompt  and  powerful  effect  upon  the  lesions  of  syphilis,  par- 
ticularly those  of  the  secondary  stage  of  the  disease  and  certain  affec- 
tions of  the  eye  and  connective  tissues.  This  effect  is  prolonged  and 
continued,  the  calomel  presumably  remaining  at  the  point  of  injection 
as  a  magazine  from  which  steady  absorption  goes  on. 

In  the  tertiary  stage,  in  conjunction  with  the  iodides,  this  method 
of  treatment  is  extremely  valuable  when  the  integrity  of  vital  organs 
is  threatened  or  when  the  lesions  resist  ordinary  treatment.  Among 
the  advantages  of  the  hypodermic  administration  of  calomel  should 
be  mentioned  its  possible  diagnostic  value  in  surgical  cases.     Accord' 


THE    TEEATMENT   OY   SYPHILIS.  1029 

ing  to  Jullien,  injections  of  calomel  will  quickly  determine  by  their 
favorable  action,  or  the  reverse,  whether  certain  ulcerating  neoplasms 
are  syphilitic  or  malignant.  He  holds  that  the  therapeutic  diagnosis 
of  syphilis  may  be  clearly  defined  in  eight  days  by  injection  of  calomel. 
The  Wassermann  reaction  indicates  only  that  the  patient  has  had 
syphilis,  it  does  not  conclusively  prove  that  the  individual  lesion  is 
syphilitic. 

Metallic  mercury  is  also  one  of  the  most  popular  forms  in  which 
the  insoluble  preparations  of  the  drug  are  administered.  The  dose 
employed  is  from  five  to  thirty  grains  once  weekly.  It  is  usually  given 
in  the  form  of  gray  oil  (oleum  cinereum),  prepared  by  making  an  oint- 
ment of  mercury  with  lanolin  as  a  basis,  and  then  diluting  this  with 
almond  or  olive  oil,  or  by  triturating  metalhc  mercury  with  ethereal 
tincture  of  benzoin  and  oil  of  vasehne.  The  object  of  this  prepa- 
ration is  to  secure  a  minute  subdivision  of  the  metal  and  to  obtain 
complete  fluidity. 

Yellow  oxide  of  mercury  is,  according  to  Taylor,  the  insoluble  salt 
most  used  hypodermically.  This  preparation  seems  to  be  less  irri- 
tating than  calomel  and  almost  equally  efficient.  Watrassowski's 
formula  is  as  follows  :  ■ 

R   Hydrarg.  oxid.  flav.,  gr.  xv ; 
Acacise,  gr.  iv ; 
Aquae  destil.,  f,|i. 
Of  this,  fifteen  minims  are  injected  at  a  time. 

Of  the  other  insoluble  salts  of  mercury,  the  neutral  salicylate  in 
one  or  one  and  a  half  grain  doses  weekly,  or  in  half-grain  doses 
every  three  days  ;  thymol  acetate  in  one  and  a  half  grain  doses  at 
from  three  to  six  days'  intervals  ;  the  black  oxide  ;  the  protiodide ; 
the  tannate  ;  the  sulphate  ;  turpeth  mineral,  and  cinnabar,  may  be 
mentioned. 

The  preparations  we  have  most  frequently  employed  in  the  hypo- 
dermic treatment  of  syphilis  are  the  one  per  cent,  solution  of  sub- 
limate (see  page  1029)  and  calomel  prepared  as  follows : 

R   Hydrarg.  chlor.  mit.,  3! ; 

Petrolat,  liquid,  (purificat.),  .^i ; 
Lanolin.,  ^i. 
M.     S. — Three  minims  equal  calomel  gr.  i. 

The  dose  of  the  first  preparation  is  from  twenty  to  thirty  minims 
(one-fifth  to  one-third  grain  of  sublimate) ;  of  the  second,  three 
minims.     For  the  latter  a  special  syringe  is  required. 

Both  these  preparations  sometimes  caused  pain,  severe,  prolonged, 
and  even  incapacitating,  although  previous  injections  were  painless. 
When   the   injections  were   often   repeated   the  pain   became  more 


1030  GElSriTO-URIlSrAEY   DISEASES   AND   SYPHILIS. 

severe.  Even  in  the  comparatively  full  dosage  employed  in  the  use 
of  the  soluble  preparations — that  is,  one-fifth  to  one-third  of  a  grain 
of  sublimate  three  times  a  week — symptoms  did  not  disappear  so 
rapidly  but  that  we  felt  it  necessary  to  employ  inunctions  and  at  times 
internal  medication.  Most  of  the  injections  were  given  in  the  dorsal 
region.  In  every  case,  before  administering  mercury  in  this  manner, 
careful  examination  of  the  urine  was  made  for  the  purpose  of  know- 
ing the  condition  of  the  kidneys,  since  in  cases  of  nephritis  there  is 
always  danger  of  fatal  salivation. 

This  treatment  is  so  conducted  that  we  know  exactly  where  each 
injection  has  been  driven  in ;  this  is  particularly  important  when 
insoluble  preparations  of  mercury  have  been  employed,  since,  in 
beginning  salivation,  the  foci  of  injection  must  be  cut  down  upon  at 
once  and  any  remaining  mercury  cleaned  out.  For  each  patient  a 
chart  is  made,  roughly  outlining  his  dorsal  region.  Small  circles  are 
drawn  in  the  middle  of  the  dorsal  region  from  above  downward, 
representing  the  first  six  dorsal  spinous  processes.  The  first  injec- 
tion is  usually  administered  half  an  inch  to  the  right  of  the  spinous 
process  of  the  first  dorsal  vertebra,  the  needle  being  driven  vertically 
inward.  The  next  injection  is  given  half  an  inch  to  the  right  of  the 
spinous  process  of  the  second  dorsal  vertebra,  thus  passing  down  to 
the  sixth,  when  injections  are  begun  on  the  left  side  and  continued  in 
the  same  way.  The  method  of  recording  the  seat  of  these  injections 
with  the  rough  diagram  just  described  is,  of  course,  obvious.  In  some 
cases  where  the  back  is  extremely  sensitive,  injections  are  driven 
into  the  buttock,  but  we  notice  that  in  this  region  they  are  not  less 
painful. 

Value  of  the  Hypodermic  Method. — After  a  careful  review  of  the 
opinions  of  the  most  distinguished  syphilographers  and  a  fairly  ex- 
tended trial  of  the  method,  it  seems  safe  to  assert  that  the  hypodermic 
treatment  of  syphilis  has  not  as  yet  shown  results  which  warrant  its 
adoption  as  a  routine  method,  to  the  exclusion  of  or  in  preference  to 
other  methods,  but,  on  the  contrary,  has  some  apparently  insuperable 
disadvantages,  and  even  dangers,  which  render  it  improbable  that  it 
will  ever  be  so  adopted.  This  does  not  apply  to  the  employment 
of  hypodermics  in  exceptional  cases. 

Indications. — The  indications  for  the  use  of  this  method  may  be 
summarized  as  follows.  Mercury  should  be  administered  hypo- 
dermically — 

1.  In  those  cases  in  which  other  methods  of  treatment  have  failed 
or  cannot  be  applied  because  of  especially  sensitive  conditions  of 
either  the  gastro-intestinal  mucous  membrane  or  the  skin. 


THE   TREATMENT   OF  SYPHILIS.  1031 

2.  In  those  cases  in  which,  because  of  grave  and  advancing  lesions, 
rapid  mercurialization  is  absolutely  necessary. 

3.  In  those  cases  characterized  by  obstinate  localized  lesions 
which  can  be  most  directly  reached  by  this  plan  of  heatment. 

4.  Possibly  in  those  cases  in  which  early  differentiation  between 
syphilis  and  malignant  disease  or  tubercular  ulceration  is  extremely 
important. 

5.  Possibly  when  it  is  important  to  shorten  the  period  of  doubt 
intervening  between  the  appearance  of  a  chancre  and  secondary 
symptoms.  Rapid  disappearance  of  an  indurated  sore  in  conse- 
quence of  hypodermic  injection  might  throw  light  upon  the  true 
nature  of  a  suspicious  sore  without  being  open  to  all  the  objections 
which  attend  the  systematic  and  slow  administration  of  mercury  by 
the  mouth. 

Choice  of  Preparations. — The  soluble  salts  are  to  be  preferred  to 
the  insoluble  in  the  large  majority  of  cases,  because  of  greater  exact- 
ness in  the  matter  of  dosage  and  because  they  are  less  hable  to  be 
followed  by  undue  local  reaction  or  general  toxic  symptoms.  They 
are  always  to  be  employed  when  there  is  need  for  rapid  mercurial- 
ization. 

Insoluble  salts  should  be  reserved  for  cases  in  which  frequent 
visits  to  the  surgeon  are  impossible  and  in  which  no  contra-indications 
exist.  The  stability  and  solubility  of  the  bichloride  commend  it  as 
the  salt  of  choice  when  soluble  salts  are  employed.  Among  the  in- 
soluble salts  calomel  and  yellow  oxide  are  to  be  preferred.  It  should 
be  remembered  that  the  last  is  somewhat  less  active,  though  much 
less  irritating.  The  gray  oil  is  the  most  available  form  of  administer- 
ing metallic  mercury. 

Contra-indication. — In  cases  of  crippled  kidneys,  diabetes,  profound 
anaemia,  marked  atheroma,  great  debility,  or  any  profound  systemic 
dyscrasia  not  depending  directly  upon  syphihs,  the  hypodermic  method 
of  treatment  is  dangerous,  and  the  case,  even  if  urgent,  will  probably 
do  better  under  some  other  treatment. 

Vaporization. — This  method  of  introducing  mercury  into  the 
system  has  practically  been  abandoned  as  a  routine  practice,  since  it 
is  more  troublesome  than  other  methods,  is  more  difficult  to  apply 
privately,  and  is  in  the  majority  of  cases  not  attended  by  better  re- 
sults. The  drug  commonly  employed  is  calomel ;  the  average  dose 
is  twenty  grains. 

The  apparatus  consists  of  an  alcohol  lamp  placed  beneath  a  metal- 
lic saucer,  which  is  supported  on  a  tripod.  This  apparatus  is  placed 
beneath  a  cane-bottomed  chair,  upon  which  the  patient  is  seated  naked 


1032  GENITO-UEINAEY  DISEASES  Al^D   SYPHILIS. 

and  with  a  blanket  pinned  tightly  around  his  neck  and  dropping  to 
the  floor,  enclosing  the  body  and  the  chair  in  a  tent.  Thirty  grains 
of  calomel  are  placed  in  the  metallic  dish,  the  alcohol  lamp  is  lighted, 
and  the  blanket  is  draped  around  the  patient.  The  lamp  is  ex- 
tinguished at  the  end  of  twenty  minutes,  and  the  patient  is  allowed  to 
sit  for  twenty  minutes  longer  in  the  calomel  vapor ;  he  then  wraps 
himself  in  the  same  blanket  that  he  has  used  during  the  vaporization, 
and  retires  to  bed  for  a  couple  of  hours,  or  for  the  night  if  the  vapori- 
zations are  administered  before  going  to  bed.  There  should  be  some 
one  present,  or  at  least  within  call,  during  these  vaporizations,  since 
the  heat  and  the  concentrated  attention  of  the  patient  sometimes 
produce  syncope. 

This  treatment  is  indicated  when  other  methods  have  failed,  and 
particularly  in  cases  of  widely  diffused  small,  hard,  papular  syphilides, 
or  when  obstinate  or  precocious  ulcers  are  present.  It  is  then  in- 
valuable. 

Local  vaporization  is  sometimes  efficacious  in  the  treatment  of 
obstinate  plantar  or  palmar  syphilides.  The  foot  or  the  hand  may  be 
kept  in  a  box  filled  with  the  vapor  of  mercury  for  one  or  two  hours 
daily. 

Mercuric  Baths,  Thermal  Springs,  and  Heat. — Mercuric 
BATHS  administered  for  the  purpose  of  causing  absorption  of  the  drug 
have  been  little  employed,  since  other  methods  are  more  exact  and 
easier  of  apphcation.  The  value  of  such  baths,  however,  in  com- 
bating by  direct  action  certain  wide-spread  skin-lesions,  and  par- 
ticularly in  exerting  an  antiseptic  effect  upon  pustular  and  ulcerating 
eruptions,  thus  minimizing  or  altogether  preventing  the  effects  of 
pyogenic  infection,  is  undoubted. 

In  papular  and  pustular  syphihdes,  papular  and  ulcerating  gum- 
mata,  and  moist  papules,  the  baths  are  very  serviceable,  particularly 
in  cachectic  patients  who  do  not  well  support  vigorous  treatment  by 
the  mouth.  Tubercular  and  gummatous  skin  affections  are  also 
beneficially  acted  upon  by  this  method  of  treatment. 

When  the  whole  body  is  not  involved  in  the  lesions  the  partial 
bath  may  be  employed.  Lesions  about  the  genitaha  and  the  rectum 
may  be  benefited  by  a  sitz-bath,  or  in  case  of  plantar  or  palmar 
psoriasis  or  syphilitic  onychia  the  hands  or  the  feet  alone  may  be 
submerged. 

The  strength  of  the  bath  should  be  about  1  to  20,000.  Finger 
advises  that  from  two  drachms  to  an  ounce  of  corrosive  chloride 
of  mercury  should  be  dissolved  in  a  pint  of  water  and  be  added 
to  the  bath.     It  should  be  at  a  temperature  of  78°  to  80°  F.     This 


THE   TREATMENT  OF   SYPHILIS.  1033 

temperature  should  be  maintained  by  the  addition  of  hot  water  from 
time  to  time,  the  patient  remaining  in  the  tub  for  about  two  hours 
daily,  immediately  after  the  bath  is  completed  retiring  to  bed  for  an 
hour,  or,  if  it  is  administered  in  the  evening,  retiring  for  the  night. 

Thermal  Springs. — In  this  country,  the  Hot  Springs  of  Arkansas, 
abroad,  the  Baths  of  Aix,  are  widely  known  and  extensively  patron- 
ized for  the  supposed  specific  effects  of  the  water  upon  syphilis.  The 
general  opinion  of  the  profession  is,  however,  that  the  waters  of  these 
springs  have  no  special  remedial  value,  and  that  hot  salt  baths  at  the 
sea-shore,  or  hot  tub-baths  at  a  wholesome  mountain  resort,  would  be 
equally  useful  to  those  who  derive  the  most  benefit  from  the  springs. 

The  patients  who  should  be  sent  to  the  springs  are — 

1.  Those  whose  mode  of  life  is  unhygienic  and  who  cannot  be 
controlled  while  under  home  or  other  customary  influence.  This 
includes  patients  addicted  to  excesses,  especially  in  the  direction  of 
alcohol  and  tobacco,  and  those  whose  devotion  to  work  is  so  close  and 
constant  as  to  interfere  with  their  general  health.  2.  Those  whose 
symptoms  resist  full  doses  of  the  specific  drugs  or  who  are  unable  to 
take  large  doses  without  a  break-down  of  the  digestive  apparatus  or 
the  production  of  mercurial  or  iodic  intoxication.  Under  such  cir- 
cumstances, should  there  be  involvement  of  the  viscera  or  of  the 
brain  or  spinal  cord,  the  Hot  Springs  treatment  is  particularly  indi- 
cated. 3.  Those  who  with  syphilis  have  intense  syphilophobia,  and 
who  require  the  mental  impression  and  in  addition  the  tonic  influ- 
ence of  change  of  scene  and  climate.  4.  Those  Avith  defective  elim- 
ination or  with  marked  idiosyncrasy  as  regards  either  mercury  or  the 
iodides. 

Such  patients  will  derive  most  benefit  from  the  springs ;  but  it  is 
by  no  means  necessary  to  send  all  who  would  be  classed  under  any 
of  the  preceding  groups  for  thermal  treatment. 

The  course  of  treatment  adopted  at  the  springs  has  for  its  active 
principle  the  administration  of  the  specific  drugs ;  practically  no  de- 
pendence is  placed  upon  the  waters  as  curative  agents.  Aided  by  the 
increased  elimination  and  greater  tissue-activity  which  these  waters 
encourage,  larger  quantities  of  mercury  and  iodide  are  administered 
than  would  be  tolerated  under  ordinary  circumstances.  The  mercury 
is  usually  given  in  the  form  of  inunctions,  and,  if  the  symptoms  call 
for  it,  large  doses  of  the  iodides  are  administered. 

Fordyce  states  that  the  majority  of  the  patients  who  come  to  the 
Hot  Springs  use  both  the  hot  baths  and  some  form  of  mercury :  hence 
it  is  difficult  to  estimate  the  relative  value  of  each.  Patients  who  do 
not  take  mercury,  but  depend  on  bathing  or  on  drinking  the  water  for 


1034  GENITO-UKINAKY   DISEASES   AND  SYPHILIS. 

weeks  and  months,  exhibit  no  change  in  the  disease  which  can  be  at- 
tributed to  the  water.  Patients  who  come  to  the  springs  after  a  long 
mercurial  course  at  home  with  the  idea  of  "  boiling  out"  the  mercury, 
of  which  they  suppose  their  system  to  be  full,  sometimes  develop 
ptyahsm  after  a  number  of  baths,  thus  showing  that  the  waters  have 
an  influence  in  increasing  capillary  circulation,  favoring  tissue-change, 
and  causing  greater  activity  in  the  elimination  of  matter  foreign  to  the 
tissues.  Persons  coming  from  malarial  regions,  though  they  have  had 
no  previous  outbreak  of  malaria,  after  one  or  two  weeks  sometimes 
develop  typical  fever.  Gouty  subjects  are  hable  to  suffer  from  out- 
breaks of  this  trouble,  and  malignant  tumors  are  prone  to  grow  with 
increased  activity.  It  seems  reasonable  to  suppose  that  the  increased 
tissue-change  brought  about  by  the  hot  baths  will  be  useful  in  hasten- 
ing the  absorption  of  the  neoplasm  of  syphihs.  Moreover,  the  general 
health  is  often  benefited  by  change  of  air  and  scenery. 

Whatever  be  the  action  of  the  Hot  Springs,  it  is  true  that  under 
their  influence  patients  in  a  profound  state  of  cachexia  who  have  been 
unsuccessfully  treated  by  competent  physicians  sometimes  improve 
rapidly,  and  that  some  cases  of  late  syphilis  are  more  quickly  cured 
at  the  springs  than  at  home.  This  advantage,  however,  cannot  be 
claimed  for  the  early  stages.  The  use  of  hot  water  internally  and  by 
bathing  undoubtedly  increases  the  activity  of  the  excretory  organs, 
enabling  the  patient  to  tolerate  the  drug  in  larger  quantities.  Still, 
ptyalism  and  gastro-intestinal  irritability  frequently  occur.  It  is  not 
asserted  that  the  bath  treatment  prevents  relapses.  Lustgarten  states 
that  the  chief  benefit  from  the  Hot  Springs  is  from  the  hot  bath. 

Sulphur  baths  do  not  differ  in  reaction  from  those  of  ordinary 
springs.  Sodium  chloride  and  iodine  brine  baths  seem,  however,  to 
increase  oxidation. 

The  danger  incident  to  bath  treatment  lies  in  over-confidence  in 
the  healing  virtues  of  the  springs,  thus  leading  patients  to  stop  all 
treatment  after  the  symptoms  have  disappeared,  with  the  idea  that 
they  are  permanently  cured,  and  substituting  short  and  heroic  treat- 
ment for  the  prolonged  course  which  they  require.  This  is  to  be 
unsparingly  condemned. , 

Hot  Baths. — The  value  of  hot  baths  as  adjuvants  in  the  specific 
treatment  of  syphihs  is  beyond  dispute,  and  it  is  well  to  order  as  a 
routine  practice  during  the  time  that  mercury  is  administered  the  daily 
administration  of  a  hot-air  or  hot-water  bath,  continued  for  ten  to 
twenty  minutes,  and  taken  either  at  night  on  retiring  or  in  the  morn- 
ing, according  to  the  convenience  or  incUnation  of  the  patient.  The 
elimination  of  mercury  is  facilitated,  larger  quantities  are  tolerated, 


THE   TREATMENT   OF   SYPHILIS.  1035 

and  in  certain  cases  where  without  the  baths  doses  of  the  specific 
far  too  small  to  influence  materially  the  lesions  of  syphilis  produce 
beginning  ptyalism,  efficient  doses  can  be  given  without  untoward 
symptoms. 

These  baths,  if  of  hot  water,  should  be  from  100°  to  104°  F. ;  if 
of  air,  from  180°  to  200°  F.  In  ordering  them  the  question  of  idio- 
syncrasy should  be  fully  considered  ;  during  their  administration  the 
patient  should  have  an  attendant  at  hand,  in  case  syncope  be  pro- 
duced. 

Heat  thus  applied  to  the  general  surface  increases  the  elimination 
of  the  mercury,  even  in  the  urine,  probably  because  of  the  more 
active  tissue-changes  excited  by  the  bath.  Thus,  when  hydrargyrism 
develops,  the  application  of  the  hot  baths  affords  one  of  the  most 
active  and  efficient  means  of  relieving  symptoms,  since  it  promptly 
rids  the  system  of  the  excess  of  mercury.  The  hot-air  baths  seem  to 
be  particularly  serviceable,  since  they  occasion  free  diaphoresis  and 
elimination  of  the  mercury  through  the  sweat-glands  ;  in  consequence 
of  the  thirst  they  excite,  bland  liquids  are  ingested  in  large  quantities, 
and  these  being  taken  up  into  the  circulation  tend  to  increase  metabo- 
lism. 

Hot-air  baths  may  be  administered  by  placing  the  patient  in  bed, 
covering  him  with  several  blankets,  which  by  means  of  a  half  hoop 
or  other  device  are  lifted  in  the  form  of  a  tent,  and  then  putting 
beneath  the  tent  an  alcohol  lamp.  It  is  better  to  have  a  box  specially 
constructed  for  this  purpose  ;  it  can  be  made  at  an  expense  of  ten  or 
fifteen  dollars.  In  the  box  is  a  stool  on  which  the  patient  sits ;  the 
lid  is  so  arranged  that  when  it  shuts  down  the  head  alone  is  left 
exposed.  Around  the  opening  left  for  the  neck  is  packed  a  bath- 
towel.  An  alcohol  lamp  or  gas  stove  within  the  box  is  lighted,  the 
lid  and  door  of  the  box  are  closed,  and  the  patient  is  allowed  to  sweat 
for  ten  to  twenty  minutes.  He  then  takes  a  cold  shower  or  sponge 
bath,  and  dries  himself  by  vigorous  friction  with  a  coarse  towel. 
Unless  from  idiosyncrasy  these  baths  produce  weakness,  they  should 
be  continued  daily  through  the  entire  course  of  treatment. 

The  general  subject  of  hot  baths  in  the  treatment  of  syphilis  has 
been  investigated  by  Borovski. 

His  clinical  observations  were  made  on  twenty-eight  syphilitic 
patients.  Heat  was  employed  in  the  form  of  (a)  ordinary  hot- water 
baths  at  from  98°  to  104°  F.,  of  thirty  minutes'  duration  ;  (b)  artificial 
sulphur  baths  (prepared  by  adding  one  pound  of  sulphur  to  each 
bath)  at  from  100°  to  104°  F.,  of  from  twenty  to  thirty  minutes' 
duration  ;  and  (c)  hot-air  baths  at  from  180°  to  200°  F.,  of  from  fifteen 


1036  GENITO-UEINAKY  DISEASES  AND  SYPHILIS. 

to  thirty  minutes'  duration.  His  results  may  be  summarized  as  fol- 
lows. 1.  Both  tepid  and  hot-water  baths,  as  well  as  those  of  sulphur 
and  hot  air,  invariably  increase  the  elimination  of  mercury  in  the 
urine.  2.  The  elimination  proceeds  more  energetically  the  higher 
the  temperature  to  which  the  patient  is  exposed.  3.  The  cause  of 
such  intensified  excretion  of  mercury  should  be  sought  in  an  increase 
of  the  systemic  metaloHsm,  accompanied  by  the  disintegration  of 
mercurial  albuminates.  4.  A  mercurialized  patient's  organism  can 
be  completely  freed  from  mercury  by  means  of  the  systematic  em- 
ployment of  heat  in  one  form  or  another.  5.  In  cases  of  mercurial- 
ism,  when  the  ehmination  of  mercury  ceases  spontaneously,  the  drug 
can  be  made  to  reappear  in  the  secretions  by  the  use  of  hot  baths. 
6.  Mercurial  stomatitis  can  be  cured  by  heat  more  quickly  than  by 
any  other  means.  7.  Hot-air  baths,  while  inducing  an  enormous 
perspiration,  promote  the  elimination  of  mercury  also  through  the 
sweat-glands.  The  total  quantity  of  sweat  excreted  during  a  bath 
amounts  to  four  hundred  cubic  centimetres  and  more  ;  that  of  mer- 
cury in  the  sweat  to  1.6  milligramme  and  more  per  four  hundred 
cubic  centimetres.  Hence,  as  a  means  of  freeing  the  patient's  system 
from  mercury,  they  should  be  preferred  to  all  other  baths.  8.  The 
appearance  of  mercury  in  the  sweat  naturally  suggests  that  diapho- 
retics generally  are  useful  adjuvants  in  the  treatment  of  mercuriahsm. 
0.  Tepid  baths  (88°  F.)  should  be  resorted  to  only  in  cases  of  hydrar- 
gyrosis  in  which  higher  temperatures  are  contra-indicated  on  some 
grounds.  10.  Hot-air  baths  are  borne  by  patients  better  than  hot- 
water  ones  (98°  F.),  which  sometimes  give  rise  to  fainting.  11.  Hot-air 
baths  at  from  170°  to  180°  F.,  of  twenty  minutes'  duration,  are  borne 
better  than  those  at  from  140°  to  160°  F.,  of  thirty  minutes'  duration, 
while  the  physiological  and  therapeutical  effects  of  the  former  are 
practically  identical  with  those  of  the  latter.  12.  In  persons  having 
an  idiosyncrasy  against  mercury  the  employment  of  heat  sometimes 
affords  the  possibility  of  safely  continuing  mercurial  treatment.  13. 
Hot-air  baths,  while  inducing  intense  thirst,  involve  an  increased  in- 
gestion of  fluids,  which  in  its  turn  leads  to  an  increase  in  the  bodily 
metabolism.  14.  As  regards  the  elimination  of  mercury  from  the 
organism,  artificial  sulphur  baths  do  not  offer  any  advantages  over 
other  baths.  15.  The  time  required  for  the  complete  excretion  of  the 
metal,  from  the  patient's  system  varies  according  to  the  total  amount 
ingested,  individual  peculiarities  of  the  patient,  temperature  of  the 
baths,  etc.  16.  A  simultaneous  treatment  of  syphilis  by  mercury  and 
heat  may  sometimes  effect  a  cure  more  quickly  than  a  mercurial  treat- 
ment alone.     17.  The  heat  treatment  alone  (one  or  two  baths  daily 


THE    TEEATMENT   OF   SYPHILIS.  1037 

for  a  fortnight),  however,  usually  proves  powerless  to  bring  about  a 
cure.  18.  In  a  patient  with  a  diseased  vascular  system  the  use  of  hot 
water  requires  great  caution. 

The  local  application  of  heat  often  markedly  hastens  the  disap- 
pearance of  syphilitic  lesions  when  judicious  treatment  is  employed 
at  the  same  time.  Heat  may  be  apphed  locally  in  the  form  of  baths, 
lasting  for  one  or  two  hours,  or,  when  these  are  not  practicable,  in  the 
form  of  hot  compresses  wrung  out  of  hot  coi'rosive  chloride  solution 
and  covered  with  a  hot-water  bag. 

Indurations,  gummata,  periosteal  nodes,  and  obstinate  ulcerating 
syphilides  are  particularly  amenable  to  the  combined  action  of  local 
heat  and  general  specific  treatment. 

Kalashnikoff  observed  on  thirty-one  patients  the  effect  of  heat  ap- 
plied locally  to  the  surface.  In  cases  in  which  there  were  wide- 
spread syphihdes  the  most  affected  limb  was  placed  in  a  hot  bath 
(115°  F.)  for  half  an  hour  twice  daily.  During  the  intervals  warm 
compresses  were  kept  wrapped  about  the  parts.  Where  the  lesions 
were  in  such  portions  of  the  body  that  baths  were  impracticable,  hot 
fomentations  or  the  hot-water  bag  (111°  to  122°  F.)  were  apphed  for 
an  hour  twice  daily,  the  treatment  during  the  intervals  of  apphcation 
being  the  same  as  before.  In  one  group  no  mercurials  were  used  ;  in 
the  other,  inunctions  or  injections  of  mercury,  with  or  without  potas- 
sium iodide,  were  employed.     Kalashnikoff's  conclusions  are  : 

1.  Heat,  applied  locally,  powerfully  promotes  the  resolution  of 
syphilides  in  the  region  treated. 

2.  Syphilides  of  all  kinds  disappear  more  rapidly  under  the  influ- 
ence of  heat  than  under  that  of  a  mercurial  treatment.  The  primary 
indurated  sore  is  resolved  in  from  eight  to  sixteen  days  without 
leaving  any  sclerosis ;  roseola  in  from  four  to  eight  days ;  papules 
and  superficial  impetiginous  syphilides  in  from  eight  to  twenty-one 
days  ;  non-ulcerating  tubercles  and  gummata  in  from  seven  to  twenty- 
four  days ;  ulcerating  tubercles  and  gummata  become  cicatrized  in 
from  one  to  six  weeks ;  periostitis  disappears  in  from  one  to  twenty- 
four  days ;  osteocopic  pains  subside  in  from  three  to  eight  days. 
Commensurate  with  these  local  changes,  the  patient's  general  con- 
dition is  markedly  improved. 

3.  By  the  use  of  heat  and  mercury  a  more  rapid  absorption  is 
promoted  than  by  the  use  of  either  agent  alone. 

4.  In  cases  of  relapse  the  comparative  immunity  of  parts  treated 
by  heat  is  striking. 

5.  Heat  is  especially  indicated  in  obstinate  condylomatous  lesions 
which  refuse  to  yield  to  mercury  or  iodides. 


1038  GENITO-UKINARY  DISEASES   AND   SYPHILIS. 

6.  Heat  is  contra-indicated  in  patients  whose  weakness  is  so  great 
as  to  render  dangerous  the  necessary  mechanical  disturbance,  and 
in  cases  of  moist  papules,  where  dusting  with  calomel  will  be  found 
more  satisfactory. 

Electric  Baths. — It  is  asserted  that  by  electric  baths  there  can 
be  brought  about  active  absorption  of  mercury  by  the  skin  and  that 
the  dosage  can  be  accurately  regulated.  The  patient  is  immersed  in 
a  solution  of  sublimabe.  through  which  a  current  of  electricity  is 
passed  for  the  purpose  of  occasioning  absorption.  The  apparatus 
required  is  elaborate,  and  the  alleged  results  are  far  from  proved. 

Intravenous  Injection  of  Mercury. — Bacelli  has  treated  syphi- 
lis by  intravenous  injections  of  corrosive  sublimate  solution,  holding 
that  thus  he  secures  a  more  exact  dosage  and  a  more  rapid  and 
powerful  effect  upon  syphilitic  lesions  than  when  larger  doses  of  mer- 
cury are  given  in  other  ways.     The  solution  he  employs  is  thus  made  : 

B   Hydrarg.  chlor.  corros..  gr.  i ; 
Sodii  chlor.,  gr.  iii ; 
Aquae  destil.,  fsii. 

S. — TTLxxto  3i  daily,  ty  intravenous  injection. 

The  median  basilic  or  cephalic  vein  is  made  prominent  by  wind- 
ing a  bandag-e  tightly  about  the  middle  third  of  the  arm.  The  skin 
overlying  the  vein  having  been  thoroughly  cleansed,  the  needle,  which 
should  have  a  smooth  sharp  point,  is  boiled,  is  attached  to  the  filled 
syringe,  and  is  driven  directly  into  the  rein.  The  solution  is  then 
slowly  injected.  Absence  of  pain  and  of  subcutaneous  tumefaction 
shows  that  the  solution  is  passing  chrectly  into  the  blood-current.  In 
making  these  injections  the  syringe  and  the  lumen  of  the  needle  must 
be  entirely  free  from  air-bubbles.  Renault  and  Tomassoh  report  good 
results  from  this  method. 

Its  rapid  action  is  said  to  commend  it  in  certain  conditions. 
Tertiaries  yield  more  readily  than  secondaries.  The  papular,  mac- 
ular, and  squamous  syphihdes,  condylomata,  sore  throat,  and  the 
chancre  all  show  improvement.  But,  although  the  mercur}'  circulates 
more  readily  in  the  blood,  it  is  also  eliminated  more  rapidly.  The 
frequent  occurrence  of  sequelae  is  explained,  according  to  Blaschko, 
by  the  fact  that  after  intravenous  injection  no  trace  of  mercury  could 
be  found  on  the  fourteenth  day,  while  after  inunction  traces  of  the 
drug  are  demonstrable  for  weeks  and  months. 

In  rapidly  spreading  skin  and  mucous  membrane  eruptions,  and 
in  grave  cases  of  syphilis  of  the  central  nervous  system,  intravenous 
injections  are  warmly  commended,  some  eight  to  twelve  being  em- 


THE    TREATMENT    OF    SYPHILIS.  1039 

ployed  to  subdue  the  more  threatening  symptoms ;  the  cure  Is  com- 
pleted by  one  of  the  usual  methods  of  administering  mercury. 

The  Elimination  of  Mercury. — The  elimination  of  mercury 
begins  very  shortly  after  the  administration  of  the  drug:  thus,  ex- 
amination of  the  urine  showed  the  presence  of  m.ercury  two  hours 
after  hypodermic  injection. 

Schuster  finds  that  mercury  is  irregularly  eliminated  with  the 
urine  usually,  but  regularly  and  completely  with  the  faeces,  and  that 
this  elimination  after  an  extensive  course  of  inunction  is  complete  in 
about  six  months,  thus  showing  that  persistence  of  mercury  in  the 
organism  does  not  occur.  The  kidneys,  the  intestinal  mucous  mem- 
brane, and  the  salivary  glands  are  chiefly  active  in  eliminating  mer- 
cury from  the  system. 

The  Use  of  Iodides  in  Syphihs. — The  statement  that  "  mercury 
cures,  iodine  relieves,  syphihs"  may  through  bacteriological  research 
be  proved  to  have  a  scientific  foundation,  since  the  former  drug  is 
incontestably  superior  as  a  germicide.  This  may  explain  its  great 
value  in  the  earlier  stages  and  the  comparative  inefficiency  of  iodine 
during  that  period.  Although  this  seems  to  be  a  weh-established 
fact,  there  is  some  diversity  of  opinion  about  it,  based  upon  the  views 
which  regard  iodine  (a)  as  a  direct  specific ;  (6)  as  a  promoter  of 
the  eliminative  and  absorptive  processes.  If  the  former  view  were 
correct,  iodides  should  be  employed  oftener  and  more  freely  in  the 
secondary  stage  than  is  at  present  the  custom.  The  views  of  those 
syphilographers  who  hold  the  opposite  belief  have  been  summarized 
by  Mauriac,  who  says  that  though  the  action  of  the  iodides  may  be 
less  rapid  than  that  of  mercury,  it  is  deeper  and  more  durable,  and  is 
useful  in  those  accidents  that  are  graver,  more  destructive,  and  less 
liable  to  heal  spontaneously ;  their  sphere  of  action  is,  therefore, 
much  greater  than  that  of  mercury,  and  their  relative  harmlessness  is 
a  great  advantage.  According  to  him,  they  should  be  employed^- 
(1)  in  the  phagedenic  forms  of  the  initial  lesion  ;  (2)  in  the  beginning 
of  the  secondary  period,  especially  to  combat  the  fever  and  head- 
ache ;  (3)  in  the  erosive  and  ulcerative  syphihdes ;  (4)  in  all  the 
syphiloderms  of  transition,  the  papulo-squamous  and  papulo-tuber- 
culous ;  (5)  in  all  tubercular  and  all  malignant  syphilides ;  (6)  in  all 
subdermic  syphilitic  manifestations;  and  (7)  in  gummata  or  gumma- 
tous exudates  that  break  down  and  ulcerate. 

On  the  other  hand,  Sigmund,  though  he  sometimes  uses  the  iodides, 
in  combination  with  mercurials  or  alone,  in  the  milder  syphilitic  mani- 
festations, as  erythema  and  papillary  eruptions  with  general  lymphatic 
involvement,  does  not  think  it  possible  that  they  can  replace  the  mer- 


1040  GENITO-UKIN'AKY  DISEASES  AND   SYPHILIS. 

curials,  and  usually  reserves  them  for  employment  in  very  marked 
general  lymphadenitis,  in  scrofulous  constitutions,  in  rheumatoid  dia- 
thesis and  headaches,  accompanied  or  not  by  loss  of  sleep,  in  un- 
favorable hygienic  or  dietetic  conditions,  in  diseased  conditions  of  the 
gums  and  teeth,  and  in  general  in  all  those  conditions  in  which  the 
idiosyncrasies  of  the  patients  or  the  constitutional  comphcations 
contra-indicate  the  use  of  mercurials. 

Finger  believes  in  the  combined  use  of  the  iodides  with  the  mer- 
curials in  the  later  stages  of  the  syphilitic  treatment,  when,  he  thinks, 
they  are  superior  to  the  mercurials  ;  but  Neumann  often  uses  them 
in  the  mild  relapses  of  the  secondary  stages  and  in  those. of  the  ter- 
tiary, reserving  the  mercurial  treatment,  in  the  form  of  inunctions 
preferably,  for  the  severer  manifestations  of  both  periods.  He  con- 
siders the  iodides  especially  useful  in  periostitis  of  the  joints,  muscles, 
or  synovial  sheaths  of  tendons,  and  in  the  tertiary  affections  of  the 
eyes  and  internal  organs,  when  he  uses  mercurial  inunctions  also. 

The  value  of  the  iodides  is  so  slight  in  the  ordinary  cases  of  sec- 
ondary syphilis  that  it  is  more  than  counterbalanced  by  their  irritant 
effect  upon  the  gastro-intestinal  mucous  membrane.  As  a  rule,  their 
therapeutic  value  increases  in  direct  ratio  with  the  age  of  the  syphilis, 
but  even  in  early  syphilis  the  iodide  should  be  added  to  the  mercurial 
treatment  whenever  extensive  and  dense  exudation  has  occurred, 
whether  in  the  deeper  layers  of  the  derm,  in  the  subcutaneous  con- 
nective tissue,  in  the  periosteum  or  bone,  or  in  the  viscera. 

The  routine  use  of  the  iodides  has  been  already  sufficiently  de- 
scribed. The  old  rule  of  measuring  the  required  amount  by  the  effect 
upon  the  symptoms  is  a  useful  one.  It  may  lead  to  the  administra- 
tion of  enormous  doses,  but  if  the  diagnosis  be  assured  the  evil  effects 
of  the  drug  are  not  to  be  compared  in  gravity  with  those  of  the 
disease.  Used  in  this  way  the  practitioner  -wall  often  be  gratified  to 
find  the  iodides  finally  causing  the  disappearance  of  obstinate  osteo- 
copic  pains  or  violent  cephalalgias,  the  resolution  of  large  and  threat- 
ening gummatous  swellings,  the  subsidence  of  periosteal  nodes,  the 
cicatrization  of  enormous  ulcers,  the  return  of  power  to  paretic  or 
paralyzed  muscles,  the  cessation  of  epileptiform  convulsions,  and  even 
the  re-establishment  of  the  mental  faculties  after  they  have  been 
persistently  and  to  all  appearances  hopelessly  disordered. 

There  is  nothing  more  satisfactory  in  therapeutics  than  the  direct 
and  unmistakable  benefits  following  the  administration  of  the  iodides 
in  such  cases. 

In  doubtful  cases,  for  diagnostic  purposes,  large  and  increasing 
doses  may  also  be  given,  sometimes  with  the  result  of  promptly  re- 


THE   TKEATMENT   OF   SYPHILIS.  1041 

Vealing  the  specific  character  of  the  lesion  requiring  treatment.  It 
must  be  remembered,  however,  that  other  obscure  conditions  than 
those  resulting  from  syphihs  may  be  benefited  by  full  doses  of  the 
iodides,  and  a  faulty  diagnosis  and  prognosis  may  be  the  outcome  of 
a  too  imphcit  dependence  on  the  "  therapeutic  test."  Still  more  dan- 
gerous would  be  the  acceptance  of  the  rule  formulated  by  Jullien  and 
H.  C.  Wood.  The  former  asserts  that  "  the  existence  of  syphilis  con- 
tributes powerfully  towards  producing  tolerance  of  the  iodides.  Ex- 
perience proves,  in  fact,  that  in  persons  free  from  this  poison  the 
toxic  phenomena  of  iodism  are  much  more  to  be  dreaded.  In  the 
same  manner  an  antidote  may  be  dangerous,  or  even  fatal,  when  the 
organism  is  not  under  the  influence  of  the  poison  which  it  is  intended 
to  combat."  The  latter  says,  "  In  all  cases  of  doubtful  diagnosis  the 
so-called  therapeutic  test  should  be  employed ;  and  if  sixty  grains  of 
potassium  iodide  per  day  fail  to  produce  iodism,  for  all  practical  pur- 
poses the  person  may  be  considered  to  be  a  syphilitic." 

These  statements,  if  well  founded,  would  convey  an  important 
practical  lesson  of  the  greatest  value  in  the  diagnosis  of  obscure  con- 
ditions suspected  to  be  of  syphilitic  origin.  If  unfounded,  they  may 
be  seriously  misleading. 

A  few  years  ago  this  subject  was  discussed  at  length,  and  subse- 
quently the  opinions  of  twelve  of  the  leading  syphilographers  and 
neurologists  of  this  country  were  obtained  by  one  of  the  writers. 
They  without  exception  held  the  view  that  no  such  rule  of  diagnosis 
could  be  formulated. 

Several  formulae  have  already  been  given  for  the  administration  of 
iodides.  A  saturated  solution  (potassium  iodide,  5v ;  water,  q.  s.  ad  5i) 
is  the  most  convenient  form  in  which  to  administer  the  drug  when 
it  is  given  in  ascending  doses.  In  addition  to  this  preparation  the 
patient  may  be  ordered  compound  syrup  of  sarsaparilla,  to  a  table- 
spoonful  of  which  the  required  dose  of  iodide  can  be  added,  the 
patient  immediately  afterwards  taking  one  or  two  glasses  of  water  or 
milk.     Free  dilution  is  essential  in  avoiding  gastric  irritation. 

Rubidium  iodide  has  been  warmly  recommended,  on  the  ground 
that  it  is  less  disagreeable  than  potassium  iodide,  is  less  liable  to  dis- 
turb the  stomach,  and  is  not  so  apt  to  produce  acne  or  other  symp- 
toms of  iodism,  while  it  is  almost  equally  potent  in  causing  absorption 
of  syphilitic  infiltrates.  Iron  iodide  is  also  a  valuable  preparation, 
particularly  when  syphilitic  anaemia  is  marked.  This  may  be  given 
either  in  pill  form  or  as  a  syrup.  Lithium  iodide,  warmly  com- 
mended because  of  the  large  quantity  of  iodine  it  contains  (over 
ninety-five  per  cent.),  has  proved  too  irritating  for  use. 


1042  GElSriTO-URINARY   DISEASES   AND  SYPHILIS. 

Vegetable  infusions  and  decoctions  are  sometimes  useful  as  adju- 
vants in  the  treatment  of  syphilis,  but  have  no  specific  action  of  their 
own.     The  two  best  recognized  are  the  following : 

Succus  alterans.     {McDade's  formula) 

R   Ext.  smilacis  sarsaparillse  fl., 
Ext.  stillingiae  sylvat.  fl., 
Ext.  kappse  minoris  fl., 
Ext.  phytolaccse  decand.  fl.,  aa  f^ii ; 
Tinct.  xanthoxyli  carolin.,  fji. 
M.     S. — Take  a  teaspoonful  in  water  three  times  a  day  before  meals,  and 
gradually  increase  to  tablespoonful  doses. 

This  may  be  employed  in  alternation  with  the  mixed  treatment 
where  daily  dosing  of  the  latter  cannot  be  borne.  Taylor  suggests  as 
a  tonic  mixture : 

R   Ext.  erythrox.  cocae  fl.,  f^ii ; 
Tinct.  gentian,  comp., 
Tinct.  cinchon.  comp.,  aa  fji; 
Elix.  calisayae,  f^iv. 
M.     S. — One  tablespoonful  in  a  wineglassful  of  water  three  times  a  day,  one 
hour  after  meals. 

When  the  appetite,  digestion,  or  nutrition  needs  attention,  neither 
of  these  preparations  seems  to  be  as  efficient  as  the  following : 

R   Strychninse  sulphat.,  gr.  ij 
Acid,  phosphoric,  dil.,  f^iii ; 
Liq.  pepsinse,  q.  s.  ad  f^vi. 
M.     S. — One  teaspoonful  in  water  after  each  meal  and  before  going  to  bed. 

Zittmann'' s  treatment  of  intractable  syphilis  has  for  its  underlying 
principle,  elimination  by  diaphoresis  and  purgation. 

The  evening  before  the  treatment  is  begun,  the  patient  receives  two 
pills,  each  containing  two  grains  of  calomel,  five  grains  of  compound 
extract  of  colocynth,  and  two  grains  of  extract  of  hyoscyamus.  The 
remainder  of  the  treatment  consists  in  the  use  of  two  decoctions.  The 
first  contains  sarsaparilla  root  four  ounces,  anise-  and  fennel-seed 
each  five  hundred  grains,  senna  leaves  one  ounce,  and  liquorice  root 
four  ounces ;  these  are  bruised  and  added  to  four  gallons  of  water, 
together  with  eighty  grains  each  of  white  sugar,  alum  sulphate,  and 
calomel,  and  twenty  grains  of  the  red  sulphide  of  mercury  enclosed 
in  a  linen  bag ;  the  water  is  then  boiled  down  gently  to  one  gallon. 
This  is  decanted  and  constitutes  Decoction  No.  1.  Its  dregs  are  put 
into  thtee  gallons  of  water,  with  two  ounces  of  sarsaparilla  root,  and 


THE   TREATMENT   OF   SYPHILIS.  1043 

one  ounce  each  of  lemon-peel^  cardamom  seed  and  liquorice  root,  and 
boiled  down  to  one  gallon.     This  constitutes  Decoction  No.  2. 

The  morning  after  taking  the  purgative  pills  and  each  day  after  this, 
the  patient  drinks  half  a  pint  of  hot  decoction  No.  1  at  nine,  ten,  eleven, 
and  tv^elve  o'clock,  and  in  the  evening  half  a  pint  of  cold  decoction  No.  2 
at  three,  four,  five,  and  six  o'clock.  He  is  kept  in  bed  except  for  one 
hour  each  evening.  On  the  fifth  day  he  takes  a  hot  bath  and  is  allowed 
to  dress.  On  the  evening  of  the  fifth  day  two  of  the  above  pills  are  again 
administered,  and  the  next  day  the  routine  treatment  is  resumed.  The 
whole  course  lasts  fifteen  days. 

LOCAL  TREATMENT  OF  SYPHILIS. 
The  Chancre. — This  lesion  should  be  treated  on  general  surgical 
principles ;  the  surface  of  the  ulceration  should  be  kept  clean  by 
means  of  antiseptic  sprays  or  washes,  to  avoid  mixed  infection.  Such 
applications  are  valueless  for  the  purpose  of  aborting  constitutional 
disease,  but  are  serviceable  in  hastening  cicatrization  of  the  local 
lesion.     The  following  prescriptions  are  useful : 

R    Hydrarg.  chlor.  corros. ,  gr.  xV  ; 
Zinci  sulpho-carbolat. ,   ^i  ; 
Ext.  opii  aq.,  gr.  xii  ; 
Aquas  ros. ,  f  ^iv. 
M.     S.— Apply  by  means  of  a  pledget  of  cotton.      Change  every  two  hours. 
Dilute  if  painful. 

R   Acid,  boric,  ^ii ; 

Tinct.  opii,  f^ii ; 

Liq.  plumbi.subacetat.  dil.,  f^ii. 
M.     S. — Apply  locally. 

R   Zinci  chloridi,  gr.  v ; 

Tinct.  opii,  f,f  i ; 

Aquae  ros.,  f,^iii. 
M.     S. — Apply  locally. 

When  there  is  a  tendency  to  form  crusts,  salves  are  useful  i 

R   Emplast.  hydrarg., 

Cerat.  resin.,  aa  ^ss. 
M.     S.— Use  locally. 

R   Iodoform.,  ^ii ; 

Bals.  Peruv.,  gi ; 

Unguent,  petrolat.,  q.  s.  ad  3i. 
M.     S.— Use  locally. 

If  the  granulations  are  sluggish,  daily  touching  with  a  five  per 
cent,  silver  nitrate  solution  is  desirable. 


1044  GENITO-URIXAEY   DISEASES  AND    SYPHILIS. 

AVhen  the  chancre  is  covered  by  a  tough  pseudo-membrane,  be- 
neath which  ulceration  is  extending,  probably  from  the  reaction  of 
the  ordinary  pus-microbes,  destructive  cauterization  may  be  neces- 
sary. Nitric  acid  or  acid  mercuric  nitrate  may  be  employed,  the 
surrounding  tissues  being  protected  by  oiled  cotton  ;  antiseptic  fomen- 
tations should  follow. 

Gangrenous  and  phagedenic  chancres  require  the  same  local  appli- 
cations, supplemented  by  tonic  and  supportive  treatment. 

Of  the  dry  powders,  iodoform  is  the  most  serviceable.  It  may  be 
administered  pure  or  mixed  with  powdered  boric  acid  or  starch,  or 
may  be  applied  as  a  ten  per  cent,  ethereal  spray.  Calomel  mixed 
with  an  equal  quantity  of  lycopodium  is  a  satisfactory  local  remedy, 
Dermatol  is  an  astringent,  healing  antiseptic,  free  from  irritating  prop- 
erties and  devoid  of  unpleasant  odor.  It  may  be  used  either  as  a 
powder  or  as  an  ointment.  Aristol  is  also  serviceable.  The  dry 
powder  is  inert,  hence  it  should  be  dusted  on  the  surface  of  the 
lesion  and  a  drop  of  olive  oil  allowed  to  fall  on  it  from  a  glass  rod ; 
it  should  then  be  covered  immediately  with  some  thin,  impermeable 
substance,  under  which  solution  takes  place  slowly.  No  cotton  or 
charpie  should  be  applied  to  the  ulcer.  The  dressing  should  be  re- 
newed twice  daily. 

To  chancres  not  covered  by  crusts  or  pseudo-membrane  and  ex- 
hibiting but  slight  inflammatory  reaction,  flexible  collodion  containing 
one-tenth  part  of  iodoform  or  one-hundredth  part  of  subhmate  may 
be  apphed. 

To  urethral  and  rectal  chancres  iodoform  in  the  shape  of  sup- 
positories may  be  applied  after  copious  flushing  with  dilute  corrosive 
chloride  solution  (1  to  10,000).  These  suppositories,  made  of  cacao 
butter  or  gelatin  and  of  appropriate  shape  and  size,  should  contain 
from  two  to  five  grains  of  iodoform.  Gray  ointment  diluted  with 
three  parts  of  vaseline  is  also  serviceable  in  the  local  treatment  of 
these  lesions. 

Chancres  of  the  tongue,  mouth,  or  tonsils  are  treated  by  fre- 
quent gargling  with  corrosive  chloride  solution  (1  to  6000)  and  local 
application  of  silver  nitrate  solution  (1  to  10),  sublimate  solution 
(1  to  20),  or  iodoform  collodion  (1  to  10). 

The  Syphiudes. — Skin  lesions  may  be  benefited  by  appHcations 
of  mercury  to  the  surface  and  the  systematic  employment  of  hot 
baths. 

Erythematous  syphilides  usually  require  no  local  applications.  AVhen 
they  are  sufficiently  persistent  and  conspicuous  to  demand  treatment, 
the  following  formulae  will  be  found  useful : 


THE   TREATMENT   OF   SYPHILIS.  IQ45 

R   Hydrarg.  chlorid.  mit.,  ^i ; 

Unguent,  zinci  oxidi, 

Unguent,  petrolei  carbolat.,  aa  533. 
M.  et  ft.  ung.     S. — Apply  locally. 

B   Hydrarg.  chlorid.  mit., 

Pulv.  amyli,  aa  §i. 
M.     S. — Dust  lightly  over  the  parts  affected. 

Papular  syphilides  are  often  obstinate,  and  are  especially  benefited 
by  (1)  vapor  baths ;  (2)  inunction  and  massage ;  (3)  ointments  con- 
taining mercury  in  one  of  the  following  formulas : 

B   Ung.  hydrarg.  nitrat., 

Ung.  petrolei  carbolat.,  aa  553. 

B   Hydrarg.  ammoniat.,  9i ; 
Unguent,  aquae  ros.,  ^i. 

These  ointments  are  especially  serviceable  in  the  papulo-squamous 
eruptions.  When  these  attack  the  hand,  a  region  in  which  they  are 
persistently  recurrent,  the  local  vapor  bath  proposed  by  Wells  is 
particularly  efficacious.  The  interior  of  an  inverted  hat-box  is  filled 
with  calomel  vapor  by  means  of  a  small  alcohol  lamp  placed  beneath 
a  metal  dish  containing  calomel,  and  the  hand  is  introduced  wiOiin 
the  box  through  a  hole  cut  in  the  side. 

Mucous  Patches. — These,  for  the  most  part,  may  be  prevented 
from  appearing  in  the  mouth  by  taking  the  precautions  already  men- 
tioned (p.  1010).  When  they  appear,  they  should  be  painted  two  or 
three  times  daily  with  a  one  to  ten  per  cent,  solution  of  silver 
nitrate,  or  touched  with  the  solid  stick,  and  an  antiseptic  mouth- 
wash should  be  used,  such  as  the  following : 

B  Acid,  boric. 

Acid,  tannic,  aa  ^ii ; 
Mel.  ros.,  f^ii ; 
Aquae,  f,^vi. 
M.     S. — Use  as  a  mouth-wash. 

Or  sprays  of  listerine,  Dobell's  solution,  or  hydrogen  peroxide  may  be 
employed. 

Sometimes  a  sublimate  wash  is  useful : 

B    Hydrarg.  bichlorid.,  gr.  i ; 

Mel.  ros.,  f.^ii ; 

Aquae,  f5vi. 
M.     S. — Use  as  a  mouth-wash. 


1046  GEXITO-UPvlXAET   DISEASES   AXD   SYPHILIS. 

Iodine,  applied  to  the  lesions,  is  stimulating  and  resolvent : 

R  lodi, 

Potassii  iodidi,  aa  .^ii ; 

Glycerini,  q.  s.  ad  f5i. 
M.     S.— Apply  locally. 

The  scaly  patches  should  be  touched  every  second  or  third  day 
with  ten  per  cent,  chromic  acid  solution  or  acid  mercuric  nitrate 
half  strength.  If  they  still  persist,  they  should  be  removed  by  the 
sharp  curette  or  the  actual  cautery. 

Ulcerated  patches  in  the  throat  are  benefited  by  the  same  treat- 
ment, the  lotions  being  used  as  a  gargle.  Antiseptic  sprays  are  par- 
ticularly serviceable.  In  addition,  fumigations  may  be  administered, 
as  advised  by  Mauriac  : 

R   Cinnabar.,  gr.  xv  ; 

Hydrarg.  iodidi  vir..  gr.  viiss. 
M.     S. — For  one  fumigation,  lasting  twenty-five  minutes. 

R   Hydrarg.  iodidi  vir.,  5ss ; 
Carb.  lig.,  ^iss ; 
Benzoin.,  gr.  viiss; 
Aquae,  q.  s. 
M.  et  ft.  trochisci  no.  xx. 
S. — One  to  be  burned  morning  and  night,  and  the  vapor  inhaled. 
The  use  of  tobacco  must  be  given  up  entirely,  and  the  mouth 
kept  scrupulously  clean. 

Condylomata,  if  vegetating  and  exuberant,  should  be  cauterized 
with  nitric  acid,  acid  mercuric  nitrate,  or  chromic  acid.  These  last 
two  drugs  may  produce  toxic  symptoms.  Indeed,  death  has  resulted 
from  the  topical  application  of  the  latter:  hence  it  should  not  be 
applied  to  a  large  surface. 

R   Acid,  chromic,  gii ; 
Aquae,  f^iii. 
M.     S. — Apply  locally,  to  a  limited  area. 

The  vegetations  may  also  be  destroyed  by  the  use  of  the  following 

mixture : 

R   Plumbi  oxidi,  gr.  iv  ; 

Liq.  potass,  caust.  (33  per  cent.),  TT\,cxvi. 
M.     S. — Caustic.     For  external  use  only. 

A  single  apphcation  is  usually  efficient ;  sometimes  two  or  three 
applications  are  required  at  intervals  of  two  or  three  days.  After 
this  caustic  is  applied,  the  affected  surface  is  dusted  with  iodoform. 
A  cicatrix  forms  in  from  three  to  ten  days. 


THE   TEEATMENT   09  SYPHILIS.  1047 

Bumstead  and  Taylor  commend  the  following  mixture,  painted 
on  after  careful  drying : 

B   Acidi  salicylici, 

Ext.  cannabis  indicae,  aa  gr.  xxx  ; 
Collodion,  (flexilis),  si.     M. 

Mild  cases  require  no  local  treatment  beyond  cleanliness,  drying, 
and  dusting  with  calomel. 

When  the  papillary  overgrowth  is  extensive,  it  should  be  removed 
by  the  knife,  the  resulting  raw  surface  being  closed  by  skin  trans- 
plantation if  necessary. 

Pustular  and  Pustulo-Crustaceous  Syphilides. — It  is  particularly  in 
this  class  of  cases  that  the  mercury  and  vapor  baths  are  serviceable, 
supplemented  by  the  calomel  and  zinc  ointment.  (See  p.  1045.)  The 
latter  may  be  used  on  the  face  at  bedtime.  When  the  ulcerations 
are  indurated  and  crusted  the  following  prescriptions  may  be  used : 

K  Hydrarg.  bichlorid.,  gr.  ii ; 
Unguent,  hydrarg.  nitratis, 
Ung.  petrolei  carbolat.,  aa  ^ss. 

B  Hydrargyri  oxidi  rub.,  .^ii ; 
Unguent,  zinci  oxidi,  ,^vi. 

Leg  ulcers  should  be  cleansed,  strapped,  and  bandaged.  If  they 
refuse  to  heal  under  this  treatment,  the  whole  surface  and  the  sur- 
rounding skin  may  be  covered  in  with  a  piece  of  thinly  spread  plaster 
containing  equal  parts  of  emplastrum  hydrargyri  and  emplastrum 
cerati ;  over  this  is  applied  a  tight  bandage  which  includes  the  foot 
and  leg.  Dressings  should  be  repeated  in  accordance  with  the  amount 
of  discharge. 

Tuhey^Gular  Syphilides,  Gummata,  and  Periosteal  Nodes,  when  non- 
ulcerated,  may  best  be  treated  locally  by  the  continuous  application 
over  their  surface  of  the  following  ointment  spread  on  a  piece  of  lint : 

R   Ung.  iodi  comp.,  ^i ; 
Ung.  belladonnae,  ^ii ; 
Ung.  hydrarg.,  giii ; 
Ung.  petrolei  carbolat.,  ^iv. 

This  ointment  may  be  combined  with  the  local  use  of  heat,  a  hot- 
water  bag  being  applied  to  the  lesion  for  as  many  hours  a  day  as  is 
practicable. 

Chronic  persistently  spreading  serpiginous  ulceration  should  be 
treated  by  the  prolonged  bath, — days  or  weeks  if  necessary.  If  this 
fails  the  actual  cautery  is  indicated. 


1048  GENITO-UKINAK^   DISEASES   AND   SYPHILIS. 

Ulcerations  are  curetted,  cleansed,  and  treated  on  general  prin- 
ciples. Carious  and  necrosed  bones  should  be  subjected  to  appro- 
priate surgical  measures. 

In  a  few  reported  cases  obstinate  ulcerating  syphilitic  lesions 
which  resisted  specific  treatment  recovered  promptly  after  an  attack 
of  erysipelas.  There  has  been  no  formal  effort,  however,  to  utilize 
this  fact  in  the  treatment  of  such  lesions. 

THE  TREATMENT   OF   HEREDITARY   SYPHILIS. 
The  treatment  of  inherited  syphilis  may  be  considered  under  the 
following  heads : 

1.  The  prophylactic  treatment  of  the  parents  before  conception; 

2.  The  treatment  of  the  mother  during  pregnancy ; 

3.  The  treatment  directed  to  the  child. 

1.  The  prophylactic  treatment  before  conception  is  that  already 
described  as  appropriate  to  syphilis,  except  that  more  attention  is 
paid  to  the  general  hygiene  applicable  to  the  sexual  relations,  and 
every  effort  is  made  to  suppress  by  full  doses  of  mercury  any  mani- 
festation of  active  syphilis. 

Probably  the  most  important  point  in  prophylaxis,  as  far  as  the 
practitioner  is  concerned,  is  his  advice  in  regard  to  marriage,  or,  if 
this  has  already  been  consummated,  in  regard  to  preventing  concep- 
tion from  taking  place. 

The  doctrine  that  it  is  proper  to  permit  a  syphilitic  patient  to 
marry  two  and  a  half  years  after  infection  is  dangerous.  Though  it  is 
true  that  a  large  proportion  of  patients  who  marry  within  these  limits 
have  healthy  children,  there  is  a  minority  who  transmit  the  disease 
and  who  infect  their  wives.  The  earliest  period  at  which  marriage 
should  take  place  with  the  consent  of  the  physician  is  four  years,  and  the 
responsibility  of  contracting  such  relations  at  an  earlier  period  than 
this  should  remain  solely  with  the  patient. 

If  syphilis  is  acquired  after  marriage,  four  years  at  least  should  be 
allowed  to  elapse  before  conception  is  permitted. 

When,  in  spite  of  due  warning,  or  perhaps  from  lack  of  it,  marriage 
has  taken  place  and  the  sexual  relations  are  established,  active  treat- 
ment of  the  diseased  partner  is  imperative. 

2.  The  Treatment  of  the  Mother. — Whether  the  mother  is  pre- 
viously syphilitic,  or  has  conceived  by  a  syphilitic  husband,  or  has 
contracted  the  disease  after  impregnation,  she  is  treated  in  accordance 
with  the  principles  already  laid  down.  Mercury  is  pushed  to  its  full 
physiological  hmit,  and  is  advantageously  combined  with  moderate 
doses  of  potassium  iodide.  Special  care  must  be  taken  not  to  allow 
the    medication    to    produce   gastro-intestinal    irritation,   since    this 


THE  TKEATMENT   OF   SYPHILIS.  1049 

strongly  predisposes  to  the  production  of  abortion.  When  the  mother 
is  thus  treated  she  will  probably  bear  a  living  child,  and  one  either 
healthy  or  exhibiting  syphilis  in  a  mild  form. 

3.  The  Treatment  of  the  Child  after  Birth. — Since  the  pathology, 
stages,  and  general  course  of  hereditary  syphilis  are  similar  to  those 
of  the  acquired  disease,  treatment  is  conducted  on  the  plan  already 
described. 

In  hereditary  syphilis  the  treatment  is  modified  somewhat  by  the 
following  considerations : 

1.  There  is  always  a  more  or  less  profound  cachexia  influencing 
all  the  nutritive  and  formative  processes,  and  in  itself,  aside  from 
specific  lesions  of  vital  organs,  threatening  life. 

2.  During  the  secondary  period  lesions  corresponding  to  the  ter- 
tiary type,  particularly  gummata,  are  frequent. 

The  cachexia  and  its  results  are  combated  by  supplementing  the 
specific  treatment  by  one  which  is  stimulating  and  supporting.  Special 
attention  should  be  paid  to  the  nutrition.  The  nurse  of  the  child 
should,  of  course,  be  its  mother,  since  it  cannot  convey  the  disease 
to  her.  If  the  child  cannot  be  fed  at  the  breast,  its  chances  for  sur- 
vival are  greatly  reduced.  The  selection  of  the  most  nutritious  and 
easily  digested  artificial  food  then  becomes  a  matter  of  cardinal  im- 
portance. Tonic  treatment  should  be  employed,  iron  iodide,  cod- 
liver  oil,  and  preparations  of  the  hypophosphites  being  most  useful. 

The  iodides  are  given  in  conjunction  with  mercury  because  of  the 
frequent  early  appearance  of  tertiary  lesions. 

Routine  Treatment  of  Hereditary  Syphilis. — The  children  of 
syphilitic  parents  may  exhibit  characteristic  lesions  at  birth ;  they 
may  remain  apparently  healthy  for  several  weeks  and  then  suffer 
from  typical  secondaries ;  or  they  may  remain  free  from  signs  or 
symptoms  of  syphilis  through  life. 

When  a  child  shows  characteristic  manifestations  of  the  disease  at 
birth,  immediate  treatment  is  indicated. 

When  an  apparently  healthy  child  is  born  of  syphilitic  parents,  the 
indications  are  not  so  clear,  since  there  is  no  certainty  that  the  disease 
will  ever  develop.  As  a  rule,  it  is  safe  to  wait  for  characteristic 
symptoms  when  the  parental  syphilis  is  paternal,  or  is  old,  or  when 
during  the  whole  course  of  gestation  the  mother  has  received  vigor- 
ous specific  treatment.  When  parental  syphilis  is  maternal,  is  recent, 
and  particularly  when  it  has  not  received  appropriate  treatment,  the 
child  should  be  given  the  specifics  without  waiting  for  symptoms. 

In  doubtful  cases  treatment  should  be  delayed  till  the  appearance 
of  constitutional  symptoms.     The  first  of  these  is  alteration  in  the 


X050  GENITO-UKINARY   DISEASES   AND   SYPHILIS. 

blood :  hence  repeated  comparative  studies  should  be  made  of  this 
fluid,  and  should  there  be  an  otherwise  inexplicable  diminution  of 
hsemoglobin  and  increase  of  white  corpuscles,  the  diagnosis  of  syphiKs 
should  be  considered  as  established,  certainly  so  far  as  to  constitute 
an  indication  for  treatment. 

The  routine  method  of  treatment  is  as  follows.  The  surface  of 
the  child's  abdomen  is  bathed  with  Castile  soap  and  water,  then  with 
a  saturated  solution  of  boric  acid,  after  which  it  is  thoroughly  dried. 
Mercurial  ointment  diluted  with  three  parts  of  vaseline  is  then  spread 
on  the  child's  binder,  and  the  latter  is  applied  as  usual  in  infants. 
Half  a  drachm  of  this  dilute  ointment  may  be  used  daily.  After  the 
binder  has  been  worn  for  twenty-four  hours  the  abdomen  is  again 
washed  with  soap  and  water,  followed  by  boric  acid  solution ;  a  half- 
drachm  of  the  ointment  is  then  rubbed  into  the  skin,  and  the  binder 
previously  employed  is  again  applied.  This  binder  is  changed  for  a 
fresh  one  every  fourth  day. 

Should  the  prolonged  application  of  the  ointment  produce  derma- 
titis, the  inflamed  skin  may  be  bathed  with  witchhazel  and  dusted 
with  zinc  stearate,  carbolized  talc,  or  other  healing  powder,  the  mer- 
cury then  being  administered  in  the  form  of  inunctions,  which  are 
rubbed  into  the  back,  sides,  and  front  of  the  chest,  and  the  arms, 
thighs,  and  legs,  a  fresh  skin  surface  being  chosen  each  day. 

Exceptionally,  mercurial  ointment,  even  though  used  in  this  way, 
occasions  so  much  local  reaction  that  its  surface  appHcation  must  be 
abandoned. 

When  treatment  by  the  mouth  must  be  resorted  to,  probably  the 
most  efficient  formula  is  the  follovring : 

B   Hydrarg.  cum  creta,  gr.  i-vi ; 

Sacch.  alb.,  gr.  xii. 
M.  et  div.  in  chart,  no.  xii. 
S. — One  powder  three  times  a  day ;  to  be  taken  soon  after  nursing. 

Bumstead  and  Taylor  have  used  in  many  cases : 

B   Hydrarg.  biniodidi,  gr.  i ; 
Potassii  iodid.,  3iv ; 
Syr.  sarsaparillse  comp., 
Aquae,  aa  fgii.     M. 

Of  this  mixture  a  child  one  month  old  may  take  five  drops  thrice 
daily,  increasing  the  dose  by  a  drop  every  five  days.  To  a  patient 
over  five  years  of  age  one-half  teaspoonful  may  be  given,  the  dose 
being  gradually  increased  to  one  or  one  and  a  half  teaspoonfuls. 


THE   TREATMENT    OF   SYPHILIS.  1051 

Externally,  at  the  same  time,  a  mild  mercurial  ointment  may  be 
used,  or,  better,  the  following  may  be  kept  in  contact  with  the  skin 

under  pressure : 

R   Ung.  hydrarg., 

Ung.  zinci  oxidi,  aa  §ss  ; 
Bals.  Peruv.,  ji.     M. 

In  conjunction  with  inunctions  or  the  internal  use  of  the  powders 
of  mercury  with  chalk,  potassium  iodide  may  be  given  in  a  syrupy 
solution,  in  doses  varying  from  half  a  grain  to  a  grain,  or,  if  there  be 
any  marked  tertiary  symptoms,  even  in  much  larger  doses,  three  or 
four  times  daily. 

Occasionally  nothing  whatever  will  be  retained  by  the  stomach. 
Under  such  circumstances  hypodermic  injections  are  indicated. 
These  injections  are  open  to  the  same  objections  as  obtain  against 
this  method  in  the  adult.  They  are,  however,  often  to  be  preferred 
to  internal  treatment,  and  should  be  administered  in  the  manner 
already  described. 

The  solution  of  choice  is  the  one  per  cent,  sublimate  mixture. 
(See  page  1029.)  Beginning  with  a  dose  of  one  minim  (one-hundredth 
of  a  grain)  every  second  day,  the  quantity  injected  is  gradually  in- 
creased to  two,  three,  or  four  minims. 

The  treatment,  in  no  matter  what  form,  should  be  kept  up  long 
after  the  disappearance  of  syphilitic  symptoms,  and  it  is  well  to  con- 
tinue the  mixed  treatment  till  after  puberty.  In  addition  to  the 
medicinal  treatment,  special  attention  should  be  paid  to  cleanliness 
and  hygiene.  If  possible,  the  Hfe  should  be  out  of  doors,  and  the  food 
should  be  healthy  and  invigorating. 

The  indirect  treatment  of  the  child — i.e.,  the  administration  of 
specific  medicine  to  the  nursing  mother — is  of  possible  utility  when 
other  methods  have  failed  or  must  be  temporarily  interrupted. 


INDEX. 


Abscess  of 

Bartholin's  glands,  174 
Cowper's  gland,  272 
Fallopian   tubes,   176 
groin,  47 

chancroidal,   48 
gonorrhoeal,    187 
kidnej',  577 

( see   Kidney ) 
ovaries.   170 
penis,  27 

perinephric  region,  579 
diagnosis,   584 
etiology.   580 
prognosis,   586 
symptoms,   581 
treatment,  586 
periprostatic,   727 
periurethral,   188 
prevesical,  426 
prostatic 

gonorrhogal,   190,  262,  723,  727 
tubercular,  732 
seminal  vesicles,  712 

(see    Seminal   vesiculitis) 
supraienal   capsule,   613 
testicle,  656 
Absence  of  penis,  4 

of  suprarenal  capsule,  613 
of   urethra,    71 
Accelerator  urin^  muscle,  3 
Acetonuria,  341 
Acne,   syphilitic,  872 
Addison's  disease,  614 
Adenitis 

(see  Lymphadenitis) 
Adenoma  of 
bladder,  435 
kidney,   603 
penis,   60 
Adrenal  bodies,  613 
Albltmosuria,   344 
tests   for,   363 


Albuminuria,  342 
causes   of,  342 
syphilitic,  958,  997 
tests    for,    362 
Algolagnia,  814 

Alopecia,  syphilitic,  857,  887,  980 
Alteration   in   urinary'  stream,   293 

urine,  334 
Amenorrhoea,  syphiCitic,  859 
Amorphism,    syphilitic,    987 
Amyloid  degeneration  of 
kidney,   959 
liver,  956 
Anaesthesia,   sexual,  813 
Analgesia,   syphilitic,   859 
Anatomy^    surgical,    of 
bladder,    387 
ejaculatory  ducts,  619 
epididymis,     618 
kidnej^,   524 
penis,   1 
prostate,   719 
scrotum,  615 
seminal  vesicles,  619 
spermatic  cord,   618,   702 
testicles,  615 
ureters,  504 
urethra,   68 
vas    deferens,   618 
Androgyny,  817 
Angina,  acute  syphilitic,  857 
Angioma  of 
bladder,  488 
penis,    60 
Anomalies  of 
penis,   4 

seminal   vesicles,    713 
spermatic  cord,  704 
testicle,  626 
ureters,   506 
urethra,   71 
Anorchism,   627 
bilateral,  627 

1053 


1054 


INDEX. 


Anobchism — Continued 

monorchism,    627 
Anuria,  293,  335,  516,  564 
Anus 

gonorrlioea  of,   193 

syphilis    of,    901 
Apparatus  for  urinalysis,  360 
Ardor  urin.e  in 

urethral  stricture,  217 
urethritis,    105,   121 
Argyle-Robertson  pupil,  921 
Arteritis,  gummatous,  950 

sclerous,   950 

syphilitic,  950 
Arthralgia,   syphilitic,   944 
Arthritis 

gonorrhceal.  199 

gummatous,    945 
aspermia;  800 
Atony  of  bladder,  399 
Atresia  of  urethra,  71 
Atrophy  of  bladder,  399 

of  prostate,  773 
Atrophia  neonatorum,  976 
Azoospermia,  801 

Bacilli  in  urine,  356 
Bacteriuria,   350 
Balanitis,  7,  30 

causes   of,   30 

diagnosis  of,  32 

sjmiptoms   of,   31 

treatment   of,   32 
Balanoposthitis,  7,  9,  30 

causes  of,  30 

chancroidal,  32 

diabetic,   33 

diagnosis  of,   32 

gonorrhceal,  31,  184,  186 

symptoms, of,  31 

syphilitic,    32,    33 

treatment   of,   32 
Ballottement,  renal,  607 
Bartholinitis,   168,   174 

acute,   174 

chronic,    174 

treatment   of,   174 
Baths  in  treatment  of  syphilis,  1032 
Beck's  operation  for  hypospadia,  81 
Bidet,  the,  in  chronic  prostatitis,  730 
bigelow's  lithotrite,  452 
Bilirubin  in  urine,  359 


Bladder,  387 
absence  of,  392 
adenoma   of,   435 
anatomy  of,  387 

arteries  of,  387,  389 
attachments  of,  387 
capacity  of,   387 
cul-de-sac   of,    388 
innervation   of,   389 
ligaments   of,    387 
location   of,   387 
peritoneal  covering  of,  388 
pouch  of,  388 
recto-vesical  fascia  of,  387 
structure  of,  389 
trigonum  of,  389 
urachus  of,  387,  397 
A^ascularization  of,  389 
veins  of,  390 
angioma   of,   488 
atony   of,    399 
atrophy  of,  399 
calculus   of,   440 

(see  Calculus,  vesical) 
cancer  of,  488 
carcinoma  of,  488 
character  of,   488 
complications  of,  491 
diagnosis   of,   490 
prognosis  of,  491 
symptoms    of,    489 
treatment  of,  491 
operative,  492 

cystectomy,  partial,  498 
cystotomy,  492 

instruments  for,  493 
perineal,    492 
route,   492 
suprapubic,  493 
technique,  499 
extirpation,  498 

complications   of,   500 
indications  for,  498 
instruments  for,  498 
preparation   of   patient   for, 

498 
sequelae  of,  500 
technique  of,  499 
palliative,  491    . 
congestion   of,   412 
contusion    of,   405 
cysts  of,  485,  500 


INDEX. 


1055 


Bladdek,   cysts   of — Continued 
dermoid,  501 
epithelial,  500 
hydatid,   502 
inclusion,  501 
intravesical  ureteral,  503 
residual,  502 
urachus   of,  502 
diverticula  of,  37*4 
enchondroma  of,  488 
exstrophy  of,   392 
diagnosis  of,  393 
prognosis  of,  394 
treatment   of,   394 
operative,   394 

Maydl's  operation,   396 
Moynihan's    operation,    395 
symphyseotomy,    396 
ureteral   derivation,    397 
Wood's  operation,  394 
palliative,    394 
fibroma  of,  487 
fistula  of,  437 
causes  of,  437 
diagnosis   of,   438 
symptoms  of,  437 
treatment  of,  438 
foreign  bodies  in,  483 
diagnosis    of,    484 

cystoscopic    examination,    484 
mechanism  of,   95,   483 
syiuptoms   of,   483 
treatment  of,   484 
varieties  of,  483 
hernia  of,  400 
causes  of,  400 
complications   of,   401 
cystocele,    inguinal,    401 
symptoms   of,    401 
treatment  of,  402 
hypertrophy  of,  398 
diagnosis  of,  399 
treatment   of,    399 
inflammation  of,  412 

(see   Cystitis) 
injuries  of,  402 

complications  of,  403 
diagnosis  of,  404 
extraperitoneal,    403 
intraperitoneal,    403 
prognosis  of,  404 
symptoms  of,  403 


Bladder,   injuries  of — Continued 
treatment  of,  404 

cystotomy,  perineal,  405 
suprapubic,  405 
innervation  of,  389 
loculate,    376 
lymphadenoma  of,  488 
malformations  of,  392 
malignant   disease   of,   487 
malpositions   of,   392 
multiple,  392 
myoma   of,   487 
myxoma  of,  487 
papilloma  of,  486 
paresis  of,  300 
peritoneal  coverings  of,  397 
rupture  of,  406 

causes  of,  406 

diagnosis  of,  408 

Cabot's  injection  method,  40!) 

extraperitoneal,  406 

intraperitoneal,  406 

prognosis  of,  .409 

symptoms  of,  408 

treatment  of,  410 
sarcoma  of,   487 
space  of  RetziuSj  427 
anatomy  of,  427 
suppuration  of,  427 
stricture  of,  389 
syphilis  of,  436,  960 

diagnosis   of,   437 

symptoms  of,  437 

treatment  of,  437 
tuberculosis  of,  428 

diagnosis  of,   432 
cystoscopic,  372 

etiology  of,  429 

modes  of  infection,  in,  430 

pathology  of,  430 

prognosis  of,   433 

symptoms  of,  431 

treatment  of,  433 
operative,  435 
tumors   of,  485 

adenoma  of,  485 

angioma  of,  488 

carcinoma   of,   488 

cystic,  485,  500 

diagnosis  of  malignant,  490 

enchondroma  ofj  488 

fibroma  of,  487 


1056 


INDEX. 


Bladder,  tumors  of — Continued 
location  of,  48G 
lymj^hadenoma  of,  488 
malignant,  487 
myoma  of,  487 
myxoma  of,  487 
papilloma  of,  486 
paravesical,   502 
polyp   of,   487 
prognosis  of,  491 
sarcoma  of,   487 
symirtoms  of  malignant,  489 
treatment  of,  491 
operative,  492 

cystectomy,  jjartial,  498 
cystotomy,   492 

instruments   for,  493 
perineal,   492 
route,    492 
suprapubic,  493 
technique   of,   494 
extirpation  of,  498 

complications    of,    500 
indications  for,  498 
instruments  for,  498 
preparation   of   patient   for, 

498 
sequelae  of,  500 
technique  of,  499 
resection  of,  495 
palliative,  491 
urachus,  patent,  of,   397 
vascularization  of,  389 
veins,  varicose,  of,  501 
wounds  of,  402 

complications  of,  403 
diagnosis  of,  404 
etiology  of,  402 
extraperitoneal,  403 
intraperitoneal,  403 
prognosis  of,   404 
symptoms  of,  403 
treatment  of,  404 
Blepharitis,  syphilitic,  982 
Blood  in  urine,  329,  351 
Bodies,   loose,   in  tunica  vaginalis, 

700 
Bones,  syphilis  of,  938,  988 
bottinl's      urethral     prostatotomy, 
751 

BOUFFLEUR'S     SUPRAPUBIC     PROSTATOT- 
OMY, 757 


Bougies,  229 

a  boule,  220 

filiform,   226 

flexible,  229 
Breast,  syphilis  of,  967 
Brodel's  line  in  kidney  structure, 

527 
Brou,  injection,  for  gonorrhcea,  145 
Bubo 

causes  of,  48 

chancroidal,    36,    47 

double,  48 

frequenc}'    of,    47 

gangrenous,  49 

gonorrhoeal,  187 

localization  of,  48 

phagedenic,  49 

prognosis  of,  49 

simple,   49 

suppurating,  36,  49 

symptoms  of,  48 

syphilitic,   846 

women,  in,  49 
treatment   of,   57 
Buck's  fascia,  2,  224 
Bulb  of  penis,  1 
Bulbo-cavernosus    muscle,    3 
Bulbous  urethra,  69 
Bursitis,  syphilitic,  947 

Cabot's  injection  method,  409 
Calculus,  prostatic,  773 
corpora  amylacea,  773 
diagnosis  of,  774 
symptoms  of,  774 
treatment  of,  774 
renal,  550 

aftertreatment  in,  564 
anuria   in,   564 
character  of,  550,  551 
diagnosis  of,  556 

of  uric  acid,  558 
etiology  of,  552 
location  of,  550 
mortality  in,  564 
prognosis  of,  559 
size  of,  551 
symptoms   of,   554 
treatment  of,  556 
nephrectomy,   563 

indications  for,   563 
nephrolithotomy,  560 


INDEX. 


1057 


Calculus,  renal,  treatment  of,  nephro- 
lithotomy— Continued 
indications    for,    560 
technique  of,  560 
nephrotomy,  564 
subpreputial,  7 
ureteral,  515 

diagnosis  of,   516 

location  of,  515 

mortality  in,  521 

prognosis    of,    518 

symptoms  of,  515 

treatment  of,  518 

for  colic,  518 

operative,  519 

urethral,   99 

character  of,  99 
diagnosis  of,   100 
location  of,  99 
symptoms  of,   100 
treatment  of,   101 
vesical,  440 

diagnosis  of,  445 
etiology    of,    442 
examination  for,  445 
bimanual,  445 
cystoscopic,  449 
instrument,  446 
formation  of,  440 
prognosis  in,  449 
prophylaxis,    440 
symptoms  of,  443 
treatment  of,  451 
operative,  451 
litholapaxy,   452 

aftertreatment  in,   456,  462 
Bigelow's  lithotrite,  452 
in  children,  459 
Chismore's  modification,  456 
complications,  463 
contraindications,   462 
indications  for,  461 
perineal,   457 

indications    for,    458 
preparation  for,  451 
sequelse  of,  464 
technique,  454,  461 
lithotomy,  464 
perineal,   465 

aftertreatment,  470 
bilateral,    472 
complications  of,  469 


Calculus,  vesical  treatment  of,  opera- 
tive, lithotomy,  perineal 
— Continped 
indications  for,  473 
instruments   in,   465 
lateral,   465 
median,  471 

Dolbeau's    modification, 
472 
medio-bilateral,   471 

(Civiale's   operation) 
sequelse    of,    473 
technique  of,  466 
suprapubic,    473 

aftertreatment  in,  477 
complications  in,  481 
drainage   in,    478 
sequelte  of,  481 
technique,  473 
in  women,  482 
suprapubic,    482 
technique  of,  482 
vaginal,  482 
Cancer  or  carcinoma  of 
bladder,  488 

character  of,  488 
complications  of,  491 
diagnosis  of,  490 

prognosis  of,  491  ' 

symptoms  of,  489 

treatment   of,   491 

operative,  492 

palliative,  491 

Cowper's   glands,    273   ■ 

kidney,  604 

diagnosis  of,  607 
prognosis    of,    607 
symptoms  of,  606 
treatment  of,  609 
penis,   64 

diagnosis  of,  65 
etiology  of,  65 
prognosis  of,  66 
symptoms   of,    64 
treatment  of,  66 
prostate,  775 

diagnosis  of,  776 
symptoms  of,  775 
treatment  of,  776 
scrotum,  625 

(Chimney  sweep's  cancer) 
seminal  vesicles,  719 


67 


1058 


INDEX. 


Cancer  or  carcinoma  of — Continued 
spermatic  cord,  704 
testicle,  665 

character  of,  666 
diagnosis  of,  666 
etiology  of,  665 
prognosis  of,  668 
symptoms  of,  666 
treatment  of,  668 
urethra,  107 

diagnosis  of,  107 
symptoms  of,   107 
treatment  of,  108 
Cantwell's  operation  for  epispadia, 

83 
Capacity  of  bladder,  387 
Caput  gallinaginis,  70 
Castration  for 
hsematocele,  699 
indications  for,  675 
prostate,    enlarged,    769 
technique  of,  676 
tuberculosis,   663 
tumors,  668 
Casts,  urinary,  356 
Cathelin's  urine  separator,  380 
Catheter  en  chemise,  436,  723 
Catheter  fever,  258 
Catheterism,  317 
complications  of,  749 
indications  for,  748 
in   enlarged   prostate,    748 
technique  of,  317 
Cavernous  body  of  penis,  1 
Cephalalgia,  syphilitic,  859,  909,  994 
Cerebral  syphilis,  904,  993 

(see  Syphilis  of  brain) 
Derebropathies,  syphilitic,  904 

(see  Syphilis  of  brain) 
Chancre,  824 
character  of,  824 
clinical  pathology  of,  824 
complications  of,  829 

chancroidal    inflammation,    830 
gangrene  of,  830 
simple  inflammation,  829 
papillary  outgrowth,  830 
phagedsena,  830 
serpiginous,   831 
concealed,  837 
contagion  of,  820 
diagnosis  of,  831 


Chancre,   diagnosis   of — Continued 

differential,   833 
etiology  of,  820 
extragenital,  838 

anal   region,  843 

arms,  844 

breast,   842 

cervix  uteri,  837 

digital,  844 

ear,  928 

extremities,    843 

eye,  923 

face,  838 

head,  838 

knuckles,   844 

legs,  844 

lips,  840 

diagnosis  from  epithelioma,  841 

location,  826,  838 

nipple,  843 

tongue,  841 

tonsils  and  fauces,  842 

A^accination,  844 
genital,  827 

character  of,   827 

common  position  of,  827 

coronary  sulcus,  827 

erosion,  828 

gangrenous,   830 

indurated   papule,   829 

meatus,   838 

penis,   827 

prepuce,  828 

subpreputial,   836 

urethral,   109,  838 
diagnosis,    1 10 
incubation  of,  824 
induration  of,  825 

varieties  of,  825 
location  of,  826 
lymphatic  involvement,  846 
prognosis  of,  845 
pseudo-,  820 
relapsing,  819 
sequelae  of,   846 
soft    (see  Chancroid) 
symptoms  of,  825 
treatment  of,   1005 

destruction   or   excision,    1005 
local,   1043 
Chancroid,  36 
atypical,  42 


INDEX. 


1059 


Chancroid — Continued 
auto-inoculation,    42 
bacillus  of,  37 
cause  of,  36 
classification  of,  41 
clinical  aspect  of,  40 
complications  of,  44 
diagnosis  of,  42 

differential,  43,  834 
ecthymatous,  41 
elevated  ulcer,  41 
extragenital,  39 

frequency  of,  39 
exulcerating,  41 
follicular,  41 
frequency,  38 
gangrenous,  41,  44,  46 
genital,  39 
incubation  of,  41 
induration  of,  42 
inflamed,  41 
inoculability,   38 
inoculation,  36 
technique,  40 
localization,  39 
lymphadenitis,  47 
lymphangitis,  47,  57 
mixed  infection  in,  43 
multiplicity  of,  40 
pathology  of,  39 
phagedenic,  41,  46,  47 
prognosis  of,   49 
serpiginous,    41 
subpreputial,  45 
diagnosis,  45 
symptoms    of,    41 
treatment   of,   50 
of  complications,  54 
gangrene,  56 

lymphatic  involvement,  57 
paraphimosis,  55 
phagedsena,  56 
phimosis,   54 
serpiginous,  56 
tuberculosis.  44 
urethritis,   111 
Chetwood's    perineal    prostatotomy, 

753 
Chetwood's  urethroscope,  275 
Children,  gonorrhcea  in  female,  181 

in  male,   179 
Chimney  sweep's  cancer,  625 


Chismore's  litholapaxy,  456 

Cholesterin  in  urine,  348,  300 

Chollkia,  348 

Choroiditis,  syphilitic,  926,  983 

Choroido-retinitis,   syphilitic,  926 

ChylUria,   336,   349 

Cicatricial    stricture    of    uketiira, 

208 
Circumcision,  9 

complications   of,    13 
dressings  for,  12 
hemorrhage  in,  13 
indications  for,  9 
infection  in,  14 
(Edematous  swelling  in,  14 
technique,    9,    17 
Circumference  of  penis,  220 
Civiale's  urethrotome,  245 
Cock's  perineal  section,  253 
Colle's  fascia,  225 
Colle's    immunity   in    syphilis.    819, 

972 
Colpeurynter,  Peterson's  rEctal.  474 
Compressor  urethrte  muscle,  70 
Concomitant  urethritis,  108 
Concretions  of  seminal  vesicles,  715 
Condylomata  of  penis,  31,  61 

(see  Warts,  venereal) 
Congenital  urethral  strictures,  72, 

203 
Congestion  of  bladder,  412 

causes  of,  412 
Conjunctivitis 
gonorrhoeal,   194 
diagnosis   of,   195 
etiology  of,   194 
prognosis  of,   196 
symptoms  of,  194 
treatment  of,  196 
syphilitic,   923 
Constitutional  syphilis,  849 
Contractile  urethral  stricture,  209 
Contusion  of 
bladder,  405 
cord,  spermatic,  702 
penis,  22 
prostate,   721 
testicle,    639 
prognosis,  640 
symptoms,  640 
treatment,  641 


1060 


INDEX. 


Cord,  spermatic,  702 
abscess  of,   703 
anatomy  of,  6rj 
anomalies    of,    702 
carcinoma   of,   704 
contusion  of,  702 
funiculitis,    702 
acute,  702 
chronic,  703 
phlegmonous,    703 
tubercular,   703 
hsematocele  of,  699 
hydrocele  of,   692 
acute,   692 
diffuse,   693 
encysted,  693 
funicular,  693 
inflammation  of,   702 
lipoma   of,   703 
diagnosis  of,  703 
myxoid  degeneration,  703 
recurrence   of,   703 
syniptoms  of,  703 
treatment  of,  704 
myoma  of,  704 
sarcoma    of,    704 
torsion  of,   638 
tuberculosis  of,  704 
tumors   of,   703 
varicocele  of,  704 
causes  of,   705 
diagnosis  of,  706 
prognosis   of,    708 
results  of,  708 
spermatic  plexus  in,  705 
symptoms,   706 
treatment  of,  700 
palliative,  706 
radical,   707 
excision,   707 
technique,    707 
wounds  of,   702 
Corona  glandis,  1 
Coronary  sulcus,  2,  18 
Coryza,  syphilitic,  981 
Cowper's  glands,  69 
cancer  of,  273 
cysts  of,  273 
inflammation  of.  108,  271 
COWPERITIS,   108,  271 
diagnosis  of,  272 
symptoms   of,   27 1 


CowPERiTis — Continued 

treatment  of,  272 
Cranium^  syphilis  of,  942 
Cryptorchism,   629 
complications  of,  030 

treatment  of,  636 
diagnosis  of,  632 
prognosis   of,   632 
symptoms  of,  631 
treatment   of,   633 
varieties  of,  629 
Crystals,  urinary,  358 
Cyclitis,  syphilitic,  926 
Cyst 

of  bladder,  485,  500 
dermoid  of,  501 
epithelial,  500 
hydatid,   502 
inclusion,   501 
residual,   502 
urachus,  502 
of   epididymis,   669 
intravesical    ureteral,    503 
prostatic,   776 
hydatid,  776 
retention,   776 
pyeloparanephric,  587 
renal,   009 

agglomerated,    610 
acquired,  610 
congenital,   610 
symptoms,   611 
treatment,    611 
hydatid,   611 
diagnosis,  612 
symptoms,   612 
treatment,  612 
simple,   610 
scrotal,  sebaceous,  623 
seminal  vesicles,  of,  715 
supra-renal,  614 
of  testicle,   669 
cystoma,   669 
dermoid,   674 
diagnosis,  672 
encysted    hydrocele,    669 
symptoms  of,  672 
treatment  of,  673 
Cystectomy,  498 
Cystitis,  412,  471 
catarrhal,  415 
classification  of,   412 


INDEX. 


1061 


Cystitis — Continued 
diagnosis  of,  418 

cystoscopic,  374 
etiology  of,  412 
gangi-enous,  416 
gonorrhoea!,    192 
interstitial,    415 
membranous,   415 
pathology  of,  414 
prognosis    of,    418 
pyuria  in,  416 
symptoms   of,   416 
syphilitic,  436,  960 
treatment  of 
acute,   420 
chronic,   422 
tubercular,  428 
Cystocele,  INGUIJs^^AL,  40O 
Cystoscope,   367 
Cystoscopic  diagxosis  of 
bladder,   normal,   376 

loculate,  376 
calculi,    374 
cystitis,    374 

tubercular,   373 
diseases    of    upper    urinary    tract, 

376 
diverticula,  374 
fistula,  376 
folds,  377 
foreign  bodies,  374 
papilloma,    373 
quilting  of  bladder,   373 
tuberculosis,  373 
tumors,  377 
ulceration,  374 

simple  solitary,  375 
syphilitic,  376 
thrombotic,    376 
traumatic,  375 
trophic,  376 
tubercular,   375 
Cystoscopy,  367 
diagnosis  by,  372 
errors  to  be  avoided  in,  377 
technique  of,   368 
of  ureters,   377 
Cystotomy,  402,  493 
perineal,  465 

anatomy   in  relation  to,   465 
bilateral,   472 
complications   of,    469 


Cystotomy,    perineal — Continued 
lateral,   465 
median,   471 
medio-bilateral,   473 
suprapubic,   473,   753 
technique  of 

for  calculus,  473 

for  enlarged  prostate,  752 

Dactylitis,  syphilitic,  943,  991 
diagnosis  of,  992 
symptoms   of,    99 1 
treatment  of,  992 

DArtos  of  scrotum,  615 

Dawbarn's  sx:pp.apubic  p.ladder  drain- 
age, 480 

Deafness,  syphilitic,  983 

Decortication,  subcapsular,  of  kid- 
ney, 602 

Dental  erosion,   syphilitic,  985 

Dermoid  cysts  of 
bladder,  500 
testicle,  669 

Diacetic  acid  in  itrine,  349 

Diathetic  urethritis,  106 

Dilatation,    physiological,    of    ure- 
thra, 68 

Diphtheritic  urethritis,   113 

Discharge  from  urethral  stricture, 
218 

Dislocation  of  penis,  26 
symptoms   of.   26 
treatment  of.  26 

Disseminated    .sclerosis,    syphilitic, 
996 

Diverticula,  urethral,  73 
vesical,   397 

DiVULSION      IX       URETHRAL     STRICTURE, 

254 

DOLBEAU'S   DILATOR.    472 

median  lithotomy,  472 
Dribbling     of     t'rixe    in     urethral 

strictuer,  210,  217 
Ducts,  ejagulatory 
anatomy  of,  610 
inflammation,   gonorrhoea!,    154 

treatment,   156 

obstruction  of,   804 

treatment,  804 

Ear,  syphilis  of 

acquired,  928 


10G2 


INDEX. 


Eak,   syphilis   of — Continued 

hereditary,   983 
Eburnation,  syphilitic,  939 
echinococcus 

of  bladder,  502 

of  kidney,   611 

in  urine,  355 

ECTHYMATOUS    CHAXCBOID,    41 

EcTOPY,  629 

complications   of,   631 

treatment  of,  636 
orchidopexy,  634 
treatment  of,  634 
varieties  of,  629,  630,  633 
Eczema  of  scrotum,  622 
Edebohl's  operation  of  renal  decap- 
sulation, 385 
Effemixation,  817 
Electrolysis  in  urethral  stricture, 

254 
Elephantiasis  of 
penis,  60 
scrotum,   624 
Emission,  involuntary  seminal,  795 
diurnal,  795 
nocturnal,   795 
Emphysema  of  scrotum.   621 
Enchondroma  of  testicle,  673 

of  bladder,  488 
Encysted  hematocele.  699 
Encysted  hydrocele 

of    spermatic    cord.    693 
of  epididymis,  669 
of  testicle,  669 
Endocarditis,  syphilitic,  949 
Endoscope,    273 
use  of,   278 
Valentine's,  273 
Enlarged  prostate,  733 

( see    Prostate ) 
Enteritis,  syphilitic.  901 
Enuresis,   322 
diagnosis  of,  324 
treatment   of,   324 
mechanical,   325 
medicinal,    325 
Epididymis 

anatomy   of,   618 
cysts  of,  669 
inflammation  of,  652 
(see   Epididymitis) 


Epididymis — Continued 
syphilis  of,  664,  960,  997 

treatment   of,    961 
tuberculosis  of,  658 
diagnosis   of,   661 
acute,  661 
chronic,  662,  961 
prognosis   of,    662 
symptoms  of,  660 
treatment    of,    063 
tumors  of,  665 
Epididymitis 

(see   Epididymo-orchitis) 
gonorrhceal,    191 
course  of,  646 
diagnosis  of,  646 
etiology   of,   645 
pathology  of,  647 
prognosis  of,   647 
sterility  in,  648 
symptoms  of,  645 
treatment  of,  649 
syphilitic,   859,   960 
traumatic,   645 
tubercular,   658 
urethral,  645 
Epididymo-orchitis,  652 
etiology,   652 
gout,  654 

infectious  fevers,  652 
influenza,  655 
malaria,    654 
mumps,  652 
scarlatina,  655 
smallpox,  655 
tonsillitis,   654 
typlioid  fever,  654 
variola,  655 
syphilitic,  664,  961 
traumatic,   639 

contusion,  639,  655 
strain,   642 
tubercular,  658 
diagnosis  of,  661 
eitology  of,  659 
prognosis  of,  662 
symptoms  of,  660 
treatment  of,  663 
Episcleritis,   syphilitic,   924 
Epispadia,  81 
treatment,   83 

(see  Exstrophy  of  bladder) 


INDEX. 


1063 


Epithelial  cysts  of  bladder,  500 
Epithelioma  of 
bladder,  488 

diagnosis  of,  490 
prognosis  of,  491 
symptoms  of,  489 
treatment  of,  491 
penis,   31,  G4 
diagnosis  of,   65 
etiology  of,  65 
prognosis   of,   66 
symptoms  of,  64 
treatment   of,    66 
prostate,   775 
scrotum,  625 
Epithelium  in  the  urine,  354 
Erectile  tissue  of  penis,  1 
Erectile  urethra,  anterior,  71 
Erection  in  acute  urethritis,  122 
interference  with,  17 
mechanism,   777 
painful,  122 

treatment  of,  129 
Erector  muscle  of  penis,  2 
Erethismic  urethritis,  106 
Eruptions,  syphilitic,  859 
Eruptive  urethritis,  107 
Erysipelas   of  penis,   27 
Erythema  intertrigo  of  scrotum,  621 

syphilitic,  857,  890 
Erythematous    syphilide,    861,    862, 

977 
Excision  for  urethral  stricture,  254 
Exstrophy  of  bladder,  392 
diagnosis   of,   392 
prognosis  of,  393 
treatment    of,    393 
Extirpation  of  bladder,  498 
Extragenital  chancre,  838 
chancroid,  39 
gonorrhoea,   192 
Extravasation  of  urine  in  urethral 

stricture,  223 
Exulcerating  chancroid,  41 
Eye,  gonorrhcea  of,  194 
syphilis   of,  923 
choroid,  926 
ciliary  body,  926 
cornea,   923 
hereditary,    982 
iris,  924 


Eye,  syphilis  of — Continued 
lachrymal  apparatus,  923 
muscles   of,   927 
optic  nerve,   926 
retina,  926 
sclera,    924 

Fatty  hydrocele,  692 

Fencer's     operation     foe     ureteral 

VALVE  obstruction,  507 
Fenwick's   tables   of  frequent   uri- 
nation, 290 
Fever,   urethral,   258 
acute,  259 
chronic,    260 
etiology   of,   258 
prognosis  of,  260 
symptoms  of,  259,  260 
treatment    of,    261 
Fibroma  of 
bladder,  487 
kidney,  605 
penis,  60 
scrotum,    626 
testicle,  674 
FiBRINURIA,    344 

Fistula 

rectovesical,  227 
renal,  573,  602 
ureteral,  521 
urethral,  97,  262 

gonorrhoeal,   189 
urethro-penile,  267 
urethro-perineo-scrotal,   265 
urethro-rectal,   262 
vesical,  437,  403 
causes  of,  437 
diagnosis  of,  438 
symptoms  of,  437 
treatment  of,  438 
Floating  kidney,  529 
Follicular  chancroid,  41 
abscess,  gonorrhoeal,   188 
Folliculitis 
in   female.    171 
in   male,    188 
Forceps,  phimosis,  10 
Foreign  bodies  in 
bladder,  483 

diagnosis  of,  484 

cystoscopic,    484 
symptoms  of,  483 


1064 


INDEX. 


Foreign    bodies    in,    bladder — Contin- 
ued 
ti-eatment  of,  484 
urethra,  95 

consequences   of,   97 
diagnosis   of,   97 
symptoms  of,  96 
treatment   of,   97 

FOBESKIN 

adhesions  of,  6 

treatment  of,  6j  7 
anatomy  of,  2 
anomalies  of,  6 
calculi  of,  7 
infection  of,   14 
narrowing  of,  7 
oedema  of,   14 
phimosis,  7 
acquired,    8 
complications  of,  7 
congenital,  7 
etiology  of,  7 
treatment  of,  8 
circumcision,   9 

(see  Circumcision) 
incision  of,  8 
stripping  of,  8 
Fossa  navicxjlaris,  68 
Fe^num 

abnormalities  of,  6,  22 
anatomy  of,  2 
hemorrhage  of,   14 
shortness  of,  22 
FeACTUKE  of  PENIS,  25 

complications  of,  25,  28,  297 
prognosis  of,  25 
symptoms  of,  25 
treatment  of,  25 
Frequency  of  urination 

diagnostic  significance  of,  289 
etiology,  289 
bladder 

calculus  of,  443 
changes   in,   227 
contraction  of,  292 
foreign  body  in,  484 
inflammation  of,  416 

(see  Cystitis) 
syphilis,   436, 
tuberculosis  of,   431 
functional,   291 


Frequency    of   urination,    etiology — 
Continued 
treatment   of,   292 
kidney 

calculus   of,   555 
inflammation  of,  568 
tuberculosis  of,   598 
prostate 

enlarged,   739 
inflammation  of,  726 
acute,    726 
chronic,   730 
irritable,    732 
tuberculosis  of,   733 
testicle 

tuberculosis    of,    661 
ureter 

calculus   of,   515 
urethra 

inflammation  of   ( gonorrhceal ) 
female,   acute,    169 
male,  acute  anterior,   120 
acute  posterior,   123 
chronic  posterior,   154 
Fungus  of  testicle,  657 
funiculate  hydrocele,  693 
funiculitis,   702 
acute,  702 

treatment  of,  703 
chi'onic,   703 
phlegmonous,  703 
tubercular,    703 

Gangrene  of  penis,  27,  31 

scrotum,   623 
Gangrenous  bi'BO,  49 

chancroid,   44,   54 
Garson-Petersen  dilatation  methob 

in   lithotomy,  474 
Gauge,  urethral,  220 
Gerster's  urethrotome,  246 
Glands  of  littre,  69,  206 
Glands  of  tysox,  2    , 

cysts,  60 
Glans  penis,  1,  2 
Gleet,  147,  210,  218 
Globinuria,  344 
Glossitis 

desquamative,  894 

gummatous,  895 

sclerous,   895 


INDEX. 


1065 


Glycosuria,  347 
causes  of,  347 
diagnosis  of,  364 

GONOCOCCUS 

characteristics   of,    114,    118 
culture  of,  114 
staining  of,  115 
technique  of,   116 

GONORRHCEA 

in  children 
female,    181 

urethro-vulvo- vaginitis,    181 
catarrhal,    181 
gonorrhceal,   182 
irritative,  181 
male,   179 
in  female  adult,   168 
Bartholinitis,   168,   174 
contagion  of,  168 
diagnosis  of,  169 
frequency  of,   168     • 
metritis  of,  175 
oophoritis,    176 
perimetritis,  176 
salpingitis,   169,   176 
seat  of  infection,  168 
symptoms  of,  168, 
urethritis,    170 
vaginitis,   168,   177 
vulvitis,   168,   173 
in  male,  113 

(see  Urethritis) 
complications  of,  184 
abscess,   follicular,   188 
periurethral,  188 
prostatic,    190 
balanitis,  31,  184 
balano-posthitis,   31,   184 
bubo,   187 
cystitis,    192 
epididymitis,  191 
extragenital,  192 
eye,    194 

blennorrhoea,    acute,    194 
conjunctivitis,    194 
ophthalmia,    194 
neonatorum,    195 
purulent,    194 
rheumatic,   198 
joints,   198 
lymphadenitis,  187 
lymphangitis,   187 


GoNORRHCEA,  in  male — Continued 
mouth,   194 

acute  stomatitis,   194 
nephritis,   192 
paraphimosis,    186 
pericarditis,   202 
phimosis,    185 
phlebitis.    201 
pleura,  202 
prepuce,   30 
proctitis,  193 
prostatitis,   190 
acute  simple,  190 
follicular,    190 
parenchjanatous,   190 
pyelitis,  192 
rheumatism,   198 
arthritis,   199 
periarthritis,  200 
tenosynovitis,  201 
ureteritis,    192 
vesiculitis,    191 
niedieo-legal  diagnosis,  117,   180,  182 
Gorget,  teale's  probe,  247 
Gross'  urethrotome,  246 
Gumma    (see  Syphilis) 

of  testicle,  664 
Gummatous  urethritis,   111 
Guyon's     urethral     classification-, 
218 
sign  in  renal  examination,   607 
Gynajs^dry,   817 

H.^matocele,  694 
encysted,  698 
of  spermatic  cord,   699 
diffuse,   699 
encysted,  699 
of   testicle,   698 
of  tunica  vaginalis,  695 
acute,  695 
chronic,  695 

diagnosis  of,  697 
H.^smatoporpiiyrin,  34] 
Hematuria,  329 

causes  of,  330,  345,  444,  538 
diagnosis  of,  346,  366 

cystoseope  in,   332 
in  renal  calculus,  555 
wounds  of  kidney,  545 
h.emoglobinuria,  346 
Hair,  syphilis  of,  857,  887,  980 


1066 


INDEX. 


Haedening  of  penis,  28 
Harrison's  urethrotomy,  250 
Headache,   syphilitic,   909,  913 
Heart,  syphilis  of,  949 
endocarditis,   949 
myocarditis,  949 
pericarditis,  949 
Heat   in   antisyphilitic   treatment, 

1036,  1039 
Hepatitis,   syphilitic,   953,   996 
amyloid  degeneration,  956 
precocious,  953 
tertiary,  953 
gummatous,  954 
interstitial,  953 
prognosis  of,  956 
symptoms  of,  955 
treatment  of,  956 
Hereditary  syphilis,  975 
Heredity,  syphilitic,  969 
Hernia  of  bladder,  399 
Herpes  progenitalis,  33 
diagnosis  of,   34 
etiology  of,  34 
neuralgic,  34 
prepuce,  33 
recurrent,  36 
treatment  of,  9,  35 
ulcerative,  34 
Herpetic  urethritis,  107 
HiPPURic  acid  in  urine,  358 
Homo -sexuality,  815 
hunterian  chancre,  824 
Hutchinson's   syphilitic  teeth,   980 
Hydatid  disease  of  bladder,  502 
of  kidney,  611 
of  prostate,  776 
JHydrargyrism,  1018 
Hydrarthrosis,    syphilitic,    945,    992 
Hydrocele,  677 

acute    (vaginilitis),   678 
causes  of,  678 
diagnosis  of,   678 
prognosis  of,  678 
symptoms  of,  678 
treatment  of,  678 
chronic,  680 

classification    ( Jacobson's) ,  680 
bilocular,  691,  693 
symptoms   of,   694 
treatment  of,  694 
congenital,  689 


Hydrocele,  chronic,  classification   (Ja- 
cobson's )  — Continued 
complications  of,  689 
diagnosis   of,   689 
prognosis  of,   690 
symptoms    of,    689 
treatment  of,  690 
cord,  of  the,  692 
acute,    692 
diffuse,   693 
encysted,  693 
funicular,   693 
double,  691 
fatty,  692 
in  hernial  sac,  692 
infantile,    690 
inguinal,   691 
multilocular,  689 
tunica  vaginalis,  680 
character  of,  682 
diagnosis   of,   684 
light  test,  684 
etiology  of,  681 
prognosis  of,   685 
statistics   of,   683 
symptoms  of,  683 
treatment   of,    685 
palliative,    686 
tapping,  686 

precautions    in,    686 
technique  of,  6So 
radical,   687 

choice   of  operation,   687 
excision,    687 
pathology,   67  7 
Hydrocephalus,  syphilitic,  993 
Hydronephrosis   in   urethral   stkio- 

ture,  227 
Hypernephroma,  614 
Hypertrophy  of 
bladder,  398 
penis,    5 
prepuce,   31 

prostate  gland,  734   (see  Prostate) 
testicle,  628 
Hypospadia,   73 
balanic,  73,  75 
cause  of,  74 
diagnosis  of,   77 
glandular,   73,  75 
penile,  73 
perineal,  73,  76 


INDEX. 


1061 


Hypospadia — Continued 
perineo-scrotal,  73 
prognosis  of,  77 
treatment  ofj  77 

Beck's   operation,   81 

technique   of,    77 

Wood's   operation,    80 
varieties  of,  73 

lUlOPATIIIC   CYSTITIS,   432 

Impermkable     urethral     stricture, 

209 
Impetigo,  sy^piiilitic,  872 
Impotence,  777,  779 
atonic,  783 
causes  of,   783 
diagnosis  of,  787 
genito-urinary   neuroses,   78G 
irritative,    782 
paralytic,  784 
prognosis  of,  788 
treatment   of,    789 
in  the  female,   798 
organic,  779 
causes  of,  779 
treatment    of,    780 
psychic,    781 

treatment   of,    782 
relative,   782 
urethral  stricture,  227 
Incontinence  op  urine,  322 
in  children,  32 
diagnosis  of,  324 
treatment  of,  324 
Guyon's    table,    322 
from  nervous  lesions,  322 

lesions  of  urinary  tract,  327 
without   lesions    of   urinary   tract, 
322 
Indigo  crystals  in  urine,  360 
Infarct,   renal,   587 
Inflammatory    urethral    stricture, 

203 
Influenzal  itrethritis,    113 
Ingestive  urethritis,   105 
Injuries  of 
bladder,   401 
kidney,  537 
penis,    22 
scrotum,  620 
seminal  vesicles,   713 


Injuries  of — Continued 
spermatic    cord,    704 
urethra,   89 
Insontium,  syphilis,  826 
Instillation  in  urethral  discharge, 

159 
Intestines,  syphilis  of,  901,  997 
Intravesical  ureteral  cysts,  502 
Inunctions  in  aktisyphilitic  treat- 
ment, 1015 
Inversion  of  testicle,  637 
Iodides  in  antisyphilitic  treatment, 

1016 
Iodism,   1021 

Irido-cyclitis,  syphilitic,  926 
Iritis,  syphilitic,  859,  924,  983 
Irritable  prostate  gland,  731 
Irritable  stricture,  urethral,  209 
Irritative  urethritis,  105 
Ischio-cavernous   muscle,  2 

Jacobson's  classification  of  chronic 

hydrocele,  680 
Janet's    tables    of    treatment    fob 

urethritis,  140 
Joints 

gonorrhoea  of,  199 

diagnosis  of,  200 
syphilis  of,  944,  992 
arthralgia,    944 
arthritis,  gummatous,  945 
synovitis,    944 

acute  monoarticular,   945 
acute  polyarticular,   944 
chronic   hypertrophic,    945 
(Hydrarthrosis) 

Keratitis,  syphilitic,  923,  982 
interstitial,  923,  982 
punctate,   924 
Kidney 

abscess  of,  570,  577 

perinephritic,    579 
adenoma  of,  603 
anatomy  of,  524 

size  of,   524 
anomalies  of,  528 
calculus  of,  550 

(see   Calculus,   renal) 
carcinoma  of,  604 

Senator's  statistics,  605 
contusions  of,  537 


1068 


INDEX. 


Kidney,  contusions  of — Continued 
complications  of,  538,  542 
degree   of,   538 
diagnosis  of,  544 
mortality  of,  544 
prognosis  of,   541 
symptoms  of,  538 
treatment  of,  542 
nephrectomy,   543 
technique,   547 
cysts,  609 

agglomerated,    610 
acquired,  610 
congenital,    610 
echinococcus,  611 
hydatid,    611 
parasitic,  611 
pyelo-paranephric,    587 
simple,   609 
fistula?,   573,   602 
floating,  529 
gonorrhcea  of,  192 
hydronephrosis,   589   \ 
acquired,  590 
causes,   590 
pathology,    591 
causes  of,  589 
character  of,   589 
congenital,   590 
diagnosis  of,  594 
intermittent,    592 
pathology  of,  591 
prognosis  of,  594 
symptoms  of,  593 
treatment  of,  594 
aspiration,  595 
massage,   594 
mortality,   operative,   596 
nephrectomy,  596 
nephrotomy,   595 
ureteral   catheterization   in,   595 
dangers   of,   595 
infarct,  587 

infected,    in    urethral    stricture,    227 
inflammation  of,  565 

(see  Kidney,  suppuration  of) 
injuries,   537 
insufficiency  of,  382 
determination  of,   382 
cryoscopy  in,  383 
tests,  chemical,  in,  383 
treatment  in  presence  of,  384 


Kidney — Continued 
movable,  530 

diagnosis  of,  531 
etiology  of,   530 
pathology  of,  530 
prognosis  of,   533 
symptoms   of,    530 
treatment  of,  533 
operative,  535 

mortality  of,  537 
nephrectomy,  537 
nephorrhaphy,   537 
indications  for,   535 
technique,  535 
palliative,  533 
postoperative,   536 
parasites  of,  613 
phlebitis  of,   588 
perirenal,   588 
rupture  of,  538 

complications  of,  538,  542 
degree  of,  538 
diagnosis  of,  540 
mortality  of,  544 
prognosis  of,  541 
symptoms  of,  538 
treatment  of,  542 
sarcoma  of,  605 
suppuration   of,   565 
clinical  causes  of,  567 
etiologj'  of,  565 
nephritis    (suppurative),  577 
causes  of,   577 
diagnosis  of,  578 
symptoms  of,  578 
treatment  of,  579 
perinephritis,  579 
character  of,  579 
diagnosis  of,  584 
extension  of,  581 
location  of,  581 
primary,  579 

causes  of,  580 
prognosis  of,  586 
secondary,  580 

causes  of,  580 
symptoms    of,    581 
treatment  of,  586 
pyelitis,  567 
acute,  567 
causes   of,   567 
chronic,  567 


INDEX. 


1069 


Kidney,     suppuration,     pyelitis^Con- 
tinued 
of  contracted  kidney,  568 
diagnosis  of,  569 
extension   of,   568 
gonorrhoea!,  191 
granulosa,  568 
pathology  of,  567 
prognosis  of,   569 
treatment  of,  569 
pyelonephritis,  574 
causes  ofj  574 
diagnosis  of,  575 
pathology  of,  574 
symptoms  of,  574 
treatment  of,  576 
nephrotomy,  577 
preventive,  576 
pyonephrosis,  570,  577 
causes  of,   570 
diagnosis   of,   571 
prognosis  of,  573 
symptoms  of,  571 
treatment  of,  572 
asi^iration  in,  573 
nephrectomy   in,   573 
nephrotomy   in,  573 
ureteral      catheterization      in, 
572 
suprarenal   capsule,   613 
surgical  in  urethral  stricture,  227 
syphilis  of,  958,  997 

acute   parenchymatous,   958 
amyloid   degeneration,   959 
gummatous,   959 
interstitial,    959 
precocious.   958 
tuberculosis  of,  596 
acute,  596 
chronic,   596 
diagnosis  of,  599 
etiology  of,  597 
forms   of,   597 
pathology  of,  597 
prognosis  of,  601 
treatment  of,  601 
tumors,  002 

adenoma  of,  603 
carcinoma  of,  604 
fibroma   of,   605 
hypernephroma   of,    614 
leucomyoma  of,  605 


Kidney,  tumors — Continued 
lipoma  of,  605 
malignant,   606 
diagnosis,   607 
prognosis,    608 
Senator's  statistics,  605 
symptoms,  606 
treatment,    609 
primary,  603 
rhabdomyoma  of,  606 
sarcoma   of,   605 
secondary   of,   606 
suprarenal  origin,  606 
vascularization  of,  526 
wounds,   544 

diagnosis  of,  545 
gunshot,   544 
incised,   545 
prognosis  of,  546 
IDunctured,   545 
symptoms  of,  545 
treatment   of,   546 
Koch-Weeks  bacillus,   198 
Kbeatinin,  340 

Lachrymal   apparatus,    syphilis   of, 

982 
Lafayette  mixture,  132 
Langenbuch's  nephrectomy,  548 
Larynx,  syphilis  of,  981 
Leucin,  359 

Leucocytosis  in  renal  diseases,  586 
Leucoderma,  syphilitic,  876 
Leucomyoma  of  kidney,  605 
Leucoplakia   of   tongue,    syphilitic, 

895 
Light  test  for  hydrocele,  684 
Linear  stricture  of  urethra,  207 
Lipoma  of  kidney,  605 

of  scrotum,  626 

of  spermatic  cord,   705 
Lipomyoma  of  kidney,  605 
Lipuria,   349 
Litholapaxy,  452,  454,  461 

in  children,  459 

Chismore's  modification,  456 

complications  of,  462 

contraindications   of,   462 

perineal,  457 

sequelae  of,  464 
Lithotomy,  464 

(see   Cystotomy) 


1070 


INDEX. 


Lithotomy — Continued 
perineal,  465 
bilateia],   472 
lateral,   465 

aftertreatment   in,   470 

complications    of,   469 

instruments  for,  465 

technique  of,  466 
median,  471 

Dolbeau's    modification,    472 
medio-bilateral,  473 
suprapubic,    473 

aftertreatment    of,    477 
complications  of,   481 
drainage   in,   478 
sequelae   of,    481 
technique    of,    473 
in  women,  482 
vaginal,  482 

technique  of,  482 

LiTHOTBITE,    BiGELOW'S,   452 
LiTTRE,   GLANDS    OF,    69,   206 

Lives,  syphius  of,  953,  996 
amyloid  degeneration,   956 
precocious,   953 
tertiary,   953 

gummatous  hepatitis,  954 
interstitial,  953 
prognosis  of,  956 
symptoms  of,  955 
treatment  of,  956 
Loose  bodies  in  tunica  vaginalis,  702 
Lungs,  syphilis  of,  936,  996 
Luxation  of 
penis,  26 
testicle,    638. 
Lymphadenitis    (see  Bubo) 
carcinomatous,  666 
chancroidal,  47 
gonorrhceal,   187 
inflammatory,   31 
syphilitic,  846,  851 
Lymphadenoma  of 
bladder,   488 
testicle,  673 
Lymphangioma    (see  Elephantiasis) 
of  penis,  60 
of  scrotum,  624 
Lymphangitis 
chancroidal,   47 
gonorrhceal,  29,   187 
inflammatory,  28 


Lymphangitis — Continued 
simple,   29 
syphilitic,  846 

diagnostic  table,  848 
Lymphatic  system,  syphilis  of,  951, 

993 
Lymphomata,   syphilitic,  951 

^Macules,  syphilitic,  861 
Maisoxneuve's   urethrotome,   244 
Malformations  of 
bladder,   392 
penis,   4 
urethra,   7 1 
jMalemission  of  semen,  814 
Mammary  glands,  syphilis  of,  967 
Marriage  and  syphilis,  973" 
Marsupialization      of      suprarenal 

capsule,  614 
jVLisocHisM,  814 
Mastitis,  syphilitic,  967 
acute  irritative,  967 
gummatous,   968 
Masturbation    (Onanism),  806 
influence  of,  806 
results  of,  807 
treatment  of 
in  adults,  808 
in    children,    809 
Maydl's  operation  for 

exstrophy  of  bladder,   396,  512 

ilcDADE'S    formula    IN 

antisyphilitic  treatment,   1044 
Meatotomy 
in  female,  257 
in  male,  220,  243 
Meatus  of  urethra,  68 
chancre  of,  838 
stricture  of 
female,  256 
male,   243 
Mechanical    urethritis,    107 
]\Iegalopenis,  5 
Melanin,  348 

Membranous  urethra,  68,  218 
^Iercury  in  treatment  of  syphilis, 

1012 
]\Ietritis,  gonorrhceal,   175 
acute,  175 
chronic,   175 
Metrorrhagia,  syphilitic,  859 
microcephalus,    syphilitic,   989 


INDEX. 


1071 


MiCROUONTISM,     SYPHILITIC,     987 
MiCEOPENIS,    4 

Mixed  treatment  in  syphilis,   1014 
molluscum  contagiosum 

of  scrotum,  623 
Monorchism,   627 
MoRGAGNi's  follicles,  279 
MouTii,  chancroid  of,  39 
gonorrhoea  of,  194 
syphilis  of,  826,  893 
Movable  kidney    ( see  Kidney ) ,  530 
Moynihan's  operation  FOR  exstrophy 

OF  bladder,  395 
Mucin  in  urine,  344 
Mucous  membranes,  syphilis  OF,  981 
Mucous  patches,  857,  864,  894,  977 
Muscles,  syphilis  of,  947 
Myelosyphilis,  917 

(see   Syphilis  of  spinal   cord) 
Myocarditis,  syphilitic,  949 
Myoma  of 
bladder,  502 
spermatic  cord,  706 
testicle,   675 
Myositis,  syphilitic,  947 
acute  irritative,  947 
chronic  interstitial,  947 
gummatous,  948 
Myxoid  degeneration  of  spinal  cord, 

705 
Myxoma  of 
bladder,   487 
testicle,    675 

Nails,  syphilis  of,  858,  887,  980 
Narrowing,    physiological,    of    ure- 
thra, 68 
Nasal  cavities,  syphilis  of,  930 
Navicular  fossa,   122 

region    of    urethra,    218 
Necrosis,  syphilitic,  of  bone,  938 

of  testicle,  657 
Neisser,  gonococcus  of,  194 
Neonatorum,    gonorrhceal    ophthal- 
mia, 195 
Neoplasms  of 

bladder,  485 

cord,   spermatic,   703 

Cowper's   glands,   273 

epididymis,   665 

kidney,  602 

penis,   60 


Neoplasms  of — Continued 
prostate,    775 
scrotum,  625 
seminal  vesicle,   715 
suprarenal  capsules,  606,  613 
testicle,   665 
ureter,  523 
urethra,  269 
Nephralgia,  556 

Nephrectomy,  537,  547,  563,  573,  577, 
601 
abdominal,    548 
Langenbuch's,  548 
lumbar,  547 
urine  after,   549 
Nephritis 

gonorrhceal,  192 
suppurative,  577 
causes  of,  577 
diagnosis  of,  578 
symptoms  of,  578 
treatment  of,  579 
surgical  treatment  of,  385 
syphilitic,  958 

acute   parenchymatous,   958 
gummatovis,   959 
interstitial,  959 
precocious,   958 
Nephrolithotomy,  560 
Nephrorrhaphy,  537 
Nephrotomy,   564,   573,   577 

technique  of,  573 
Nerves,  syphilis  of,  921,  993 
Nervous    system,    syphilis    of,    858, 

903 
Neuralgia 

syphilitic,  858 
testicular,    701 
Neuritis 

syphilitic,  921 
optic,    927,    983 
Neurosis,  genito-urinary  or  sexual, 

786 
Nodes,  Parrot's,  989 
Nose 

saddle  back,  932 
syphilis  of,  929,  981 
Nymphomania,  811 

Obstruction  of  urethra,  71 
CEdema  of  scrotum,  621 
CEsophagus,  syphilis  of,  900 


1072 


INDEX. 


Oligospermia,  801 

OLIGOZOOSPEKillA,     801 

Oliguria,  334,  538,  575 
Onaxism,  806 
influence   of,   806 
results  of,  807 
treatment  in  adults,  809 
in  children,  808 
Onychia,  syphilitic,   858.  887.  980 
Oophoritis,  gonorrhceal,  176 
Opalixe  plaques,  892 
Ophthalmia 

gonorrhoea!,  purulent,  194 
gonorrhoea!,   rheumatic.    198 
neonatorum,  195 
Ohthalmo-plegia,  928 
Optic  neuritis,  syphilitic,  927 
Orciiidopexy,  634 

Orchitis       (see      Epididymo-orchitis), 
652 
differential  diagnosis,  963 
from  mumps,  652 
sypliilitic,    961 
acute,   962 
gummatous,  962 
interstitial,   961 
sclerous,  961 
Organic  urethral  stricture,  205 
Osteochondritis,  syphilitic,  988 

OsTEOCOPIC  pains   IX   SYPHILIS.   853 

Osteoma  of  testicle,  675 
Osteomyelitis,  syphilitic,  939 
circumscribed,   939 
diagnosis    of,    942 
diffuse,   940 
symptoms  of,  941 
Osteoperiostitis,    syphilitic.    938 
Osteophytes,    syphilitic,    939,    992 
Ostitis 

gummatous,   939 

rarefying,    939,    989 
Otis  u'Eethrometer.  153.  220 

urethrotome,  246 
Otitis  media,  syphilitic,  929.  983 
Ovaries 

gonorrhoea  of,   176 

syphilis  of,  966 
Ovaritis,  gonorrhceal.   176 
Oxalic  acid  in  urine,  340 
Oxaluria,  340 

causes  of,  340 

diagnosis  of,  358 
Oz^na,  syphilitic,  981 


Pain  in  diseases  of  urinary  tract 
character   of,   285 
diagnostic  significance  of,  285 
intensity  of,  285 
region  of,  286 

relation  to  micturition,  288 
Palate,  syphilis  of,  981 
Palsies,    syphilitic,   904,    927,   993 
Pancreas,  syphilis  of,  957,  997 
Papilloma  of  bladder,  486 
Papular  syphilide 

of  mucous  membrane,  890,  977 
of  slcin,   862,  977 
Papulo-squamous   syphilide 
of  mouth,  892 
of  skin,  866 
PaRvEsthesia,  sexual,  814 
Paraphimosis,  17 
causes  of,   17 
gonorrhceal,    186 
symptoms  of,   18 
treatment  of,  18 
Paraphimotic  chancroid,  55 
Parasites 

of  kidney,   613 
of  scrotum,   623 
in  urine,  355 
Parasitic   cysts  of  kidney,   611 
Paronychia,    syphilitic,    888 
diagnosis    of,    889 
dry,   888 
moist,  888 
treatment  of,   889 
Parrot's  nodes,  989 
Patches,  mucous,   857,   864,   894,   977 
scaly,    892,    895 
smooth,    894 
ulcerative,  894 
Patent  urachus,  397 
Pediculosis  of  scrotum,  623 
Pemphigus,  syphilitic,  881,  978 
Pendulous  urethra,   69 
Penile   urethra,    1,    68,   218 
Pexis 

abscess  of.  27 
absence  of,  4 

accelerator  urinse  muscle  of,  3 
adenoma  of,  60 
adherent,    5 
amputation  of,  66 
accidental.   24 
partial,  66 


INDEX. 


1073 


Pe>'is,  amputation  of — Continued 

total,  67 
anatomy  of,   1 
angioma  of,  60 
anomalies  of,  4 
balanitis,  7,  30 
balano-posthitis,  7,  9,  30 
blood  supply  of,  3 
Buck's  fascia  of,  2 
bulb  of,  1 

bulbo-cavernous  muscle  of,  3 
calcifieation  of,  25 
calculi,   subpreputial,   of,   7 
cancer  of,  64 
cavernous  body  of,   1 
cellulitis  of,  27 
chancre   of,   60    (see   Chancre) 
chancroid  of,   36    (see   Chancroid) 
concealed,  4 
contusion  of,  22 
corona  glandis  of,   1 
coronary  sulcus  of,  1 
cysts  of,  60 
dermatitis  of,   26 

from  ivy  poisoning,  26 
dislocation  of,  26 
double,  5 
eczema  of.  26 
elephantiasis  of,  60 

(see   Lymphangioma) 
epithelioma  of,   31,  64 

diagnosis  of,   65 

etiology  of,  65 

localization  of,  64 

prognosis  of,  65 

symptoms  of,  64 

treatment  of,  65 
erectile  muscle  of,  2 
erectile  tissue  of,  1 
erection  of,  interference  with,   17 
erysipelas   of,  27 
fibroma  of,  60 
fracture  of,  25 

complications  of,  25,  28 

prognosis  of,  25 

s\anptoms  of,  25. 

treatment  of,  25 
fraenum  of,  2 
abnormalities  of,  6 

hemorrhage  from,  14 

shortness  of.  14 
gangiene  of,  27 


Penis — Continued 

glands  of  Tyson  of,  2 
glans  of,  1 
gumma  of,  885 
gunshot  wounds  of,  24 
hardening  of,  28 
herpes  progenitalis,  33 

(see  Herpes) 
horny  growths  of,  63 
hypertrophy  of,  5 
incised  wounds  of,  23 
inflammation  of,  26 

acute,  26 

chronic,  27 
injuries  of,  22 

ischio-cavernosus  muscle  of,  2 
lacerated  wounds  of,  24 
lymphangitis  of,  28 

gonorrhoeal,   29 

inflammatory,  28 

simple,  29 
lymphangioma  of,  60 
lymphatics  of,  3 
megalopenis.  5 
micropenis,  4 
muscles  of,  2 
nerves  of,  3 
papilloma  of,  61 

(see  Venereal  warta) 
.  paraphimosis  of,  17 

(see  Paraphimosis) 
penitis,  27 
phagedsena  of,  44 
phimosis,  7 

(see  Phimosis) 
phlebitis  of,  29 
posthitis,  30 

prepuce,  2    (see  Prepuce) 
sarcoma  of,  60 
sheath  of,  2 
skin   of,   2 
smegma  of,  2 
spongy  body  of,  1 
suspensory   ligament    of,    2 
syphilis  of,  66,  965 
tensile  strength  of,  3 
torsion  of,  5 
tuberculosis  of,  44 
tumors  of,  60 

benign,  60 

malignant,  60,   64 
Tyson  glands  of,  2 


68 


m?4: 


INDEX. 


Penis,  Tyson  glands  of — Continued 
cysts  ofj  60 

urethra  of,  1 

veins,  dorsal,  3 
varicose,   30 

verrucae,  34,  61 

•warts  of,  34,  61 

wounds  of,  23 
Penitis,  27 

Penrose's     ureteral     transplanta- 
tion, 511 
Peptonuria,  344 

Periarthritis,      gonorrhoeal     rheu- 
matic, 200 
Pericarditis,  syphilitic,  949 
Pericystitis,  426 
Perimetritis,  gonorrhceal,  176 
Perineal  section,  247 
Perineo-bulbar  urethra,  218 
Perineprhitis,  579 
Periostitis,  gummatous,  939 

precocious  syphilitic,  938 
Periprostatic  abscess,  727 
Periprostatitis,  727 
Peritonitis,  gonorrhceal,   169 
Periurethral   abscess,    gonorrhceal, 

188 
Permeable  stricture  of  urethra,  209 
Petersen's   rectal   colpeurynter,  474 
Phagedena  of  penis 
chancroidal,  44 

serpiginous,  47 
treatment  of,  56 
Phalanges,  syphilitic  dactylitis  of, 

943 
Pharynx,  syphilis  of,  981 
Phimosis,  7 

acquired,' 8 

chancroidal,  44 

cicatricial,  8 

circumscribed,  9 

complications,  7 

congenital,  7 

fissures  in,  7 

forceps,  10 

gonorrhoeal,  185 

recurrent,   17 

letained  secretion  in,  7 

treatment  of,  8 

(see  Circumcision) 
Phlebitis 

gonorrhoeal,  201 


Phlebitis — Continued 

penile,  29 

perirenal,  588 

renal,  588 

syphilitic,  951 
Phloridzin  test,  383,  750 
Phosphaturia,  338,  360 

in  cystitis,  414 

diagnostic  table  of,   157 
Phthisis,  syphilitic,  937 
Physiological    dilatation     of    ure- 
thra, 68 

narrowing  of  urethra,  68 
Pigmentary  syphilide,  876 
Plexus  of  Santorini,  390 
Pneumaturia,  350 
Pneumococcic  urethritis,   113 
Pneumonia,  syphilitic,  936,  996 
Pollutions 

diurnal,  795 

nocturnal,  795 

treatment  of,   796 

in  urethritis,  124 
Polyorchism,  626 
Polyuria,  334 

in  chronic  pyelitis,  568 

in  pyelonephritis,  575 
Posterior  muscular  urethra,  71 
Posthitis,  30 
Pouches,  lretrhal,  73 
Prepuce 

adhesions  of,  6 

anatomy  of^  2 

anomalies  of,  6 

calculi  of,  7 

cysts  of,  60 

gumma  of,  885 

infection  of,   14 

narrowing  of,  7 

oedema  of,  14 
Prevesical  abscess,  427 
Priapism,  798 

causes  of,   798 

gonorrhoeal,  122 
treatment  of,   129 

prognosis  of,   798 

treatment  of,  798 
Primary  sore  of  syphilis,  824 
Proctitis 

gonorrhceal,  193 

syphilitic,  901 
diagnosis  of,  963 


INDEX. 


1075 


Proctitis,   syphilitic — Continued 
Ijrognosis  of,  902 
symptoms  of,  902 
treatment  of,   903 
Pkofeta's  immunity,  819,  917 
Prolapse  of  ureter,  523 
Prostate 
abscess 

gonorrhcEal,  190,  262,  723 
tubercular,  733 
anatomy  of,  719 
atrophy  of,  773 
calculi  of,  773 

corora  amylacea,  732 
diagnosis  of,  774 
symptoms  of,  774 
treatment  of,  774 
carcinoma  of,  775 

treatment  of,  776 
contusion  of,  721 
cysts  of,  776 
hydatid,   776 
retention,   776 
enlarged,  733 
epithelioma  of,  775 
.   hypertrophied,  733 

clinical  classification,  744 
diagnosis  of,  740 
cystoscope  in,  743 
differential,  743 
examination  in,  741 
etiology  of,  736 
pathology  of,  735 
prognosis  of,   745 
sequelae  of,  746 
symptoms   of,   738 
treatment  of,  746 
pallia^tive,  746 

catheterism   in,   748 
complications  of,  749 
indications   for,   748 
technique  of,  317 
dilatation,      intermittent, 

urethra,   747 
hygiene,  746 
injections,  rectal,  748 
massage,  748 
medicinal,  747 
radiqal,  750 
castration,  769 

indications  for,  750 
technique  of,  772 


of 


Prostate,  hypertrophied,  treatment  of, 
radical — Continued 
preliminary  examination,   750 

preparation,   750 
prostatectomy,  754 
choice,  754 
indications   for,   754 
moi-tality  of,   768 
perineal,   median,   756 
contraindications,  762 
indications  for,  756 
technique  of,  757 
perineal,    transverse,    756 

technique,  756 
results  of,  768 
sequelse  of,  768 
suprapubic,  754 
advantages  of,  755 
objections  to,  755 
technique,  755 
prostatotomy,  751 
galvano-cautery,  752 

via       perineum        (Chet- 

wood's),  752 
suprapubic     ( Bouffleur's ) , 
753 
perineal,   752 
vasectomy,  769 

indications  for,  750 
technique,  773 
inflammation  of,  190,  723 

(see   Prostatitis) 
irritable,  730 
causes  of,  731 
diagnosis  ot,  731 
symptoms  of,  731 
treatment  of,  731 
neoplasms  of,  775 
syphilis  of,  965 
tuberculosis  of,  731 
diagnosis  of,  733 
prognosis  of,  733 
symptoms  of,  732 
treatment  of,  733 
tumors  of,  775 
carcinoma  of,  775 
cysts  of,  776 
epithelioma  of,  775 
malignant,  775 
diagnosis  of,  776 
symptoms  of,  775 
treatment  of,  776 


1076 


INDEX. 


Prostate — Continued 
sarcoma  of,  77U 
wounds  of,  722 

complications  of,  722 
prognosis  of,  722 
treatment  of,  723 
Prostatectomy,  754 
choice  of,  754 
indications  for,  754 
mortality  of,  768 
perineal,  median,   750 

contraindications,  758 
indications  for,  750 
technique,  757 
perineal,  transverse,  758 

technique,  763 
results  of,  768 
sequelae  of,  768 
suprapubic,  754 
advantages  of,  755 
objections  to,  755 
technique,  755 
Prostatic  ducts,  70 
sinus,  70 
urethra,  68,  218 
Prostatitis,  108 
acute,    723 
causes  of,  723 
complications  of,  726 
diagnosis  of,  720 
pathology  of,  728 
prognosis  of,  720 
symptoms  of,  725 
treatme.it  of,  727 
chronic,  728 
causes  of,  728 
pathology  of,  728 
prognosis  of,  720 
sequelae  of,  729 
symptoms  of,  729 
treatment  of,   730 
bidet  in,  730 
massage  in,  730 
gonorrhoea!,  190 

acute  follicular,  IPO 
parenchymatous.   190 
simple  acute,  190 
syphilitic  732 
Prostatorbhcea,   792 
causes  of,  792 
character  of,  792 
prognosis  of,  792 


Prostatorrhcea — Continued 
symjjtoms  of,  792 
treatment  of,   793 
Prostatotomy,  751 

galvano-cautery,  752 

via   perineum    (Chetwood's) ,   752 
suprapubic    (Bouffleur's),  752 

perineal,  752 
Pruritus  of  scrotum,  622 
Pseudo-chancre,  820 
pseudo-nephrosis,  507 
Psoriasis,  mucous  syphilitic,  892 
Psychical  hermaphroditism,  816 
psychopathia  sexualis,  805 
Ptyalism,  1011 
Puboprostatic  plexus,  390 
Pulmonitis,  syphilitic,  937 
Pustular  syphilide,  870 
Pyelitis,  567 

gonorrhoeal,  192 
Pyelo- nephritis,  574 

in  urethral  stricture,  227 
Pyeloparanephric  cyst,  587 
Pyonephrosis,  570,  577 

calculous,  564 
Pyorbhcea     alveolaris,      syphilitic, 

898 
Pyuria,   352 

in  cystitis,  416 

intermittent,  517,  576 

in  pyelitis,  568 

in  pyelonephritis,  575 

in  pyonephrosis,  571 

in  renal  calculus,  556 

in  renal  tuberculosis,  599 

in  suppurative  nephritis,  578 

Reaction,  urinary,  336 
Rectovesical  fascia,  387 

fistula  in  urethral  stricture,  227 
pouch,  388 
Rectum  and  anjjs 

gonorrhoea  of,   193 
syphilis  of,  901 
diagnosis  of,  903 
prognosis  of,  902 
symptoms  of,  902 
treatment  of,  903 
Renal  calculus    (see  Calculus),  550 
Renal  capability,  382 

tests,  383 
Renal  colic,  515 


IXDEX. 


10  < 


Renal  fistula,  602 
Renal  infarct,  587 
Residual  urine 

in  enlarged  prostate,  7^9 
in  urethral  stricture,  2'28 
Retention  cyst  of  prostate,  776 
Retention  of  urine,  294 
effects  of,  297 
etiology  of,  299 

blocking  of  urethra,  302 
congestion,   301 
inflammation,  acute,  301 
paresis,  local,  300 
prostatic  enlargement,  304 
diagnosis,  307 
symptoms,   306 
treatment,  307 
aspiration,   316 
continuous        catheteriza- 
tion, 312 
stricture  of  urethra,  217,  320 
diagnosis,  320 
treatment,  321 
traumatism,  324 
incomplete,  317 
treatment,  319 

instructions  in  re  catheter  use, 
317 
Retinitis,  syphilitic,  926,  983 

choroido-,  syphilitic,  926 
Retrograde  catheterization,  253 
Retzius,  space  of,  427 
Rhabdomyoma  of  kidney,  606 
Rheumatism 
gonorrhoeal,  198 
ophthalmia,  198 
Rhinitis,  syphilitic,  929 

RONTGEN   ray   STERILITY,   801 
ROSENBERGER's    operation    FOR    EPISPA- 
DIA, 89 

Roseola,  syphilitic,  861,  977 
RupiA,  syphilitic,  881 
Rupture  of  *" 

bladder,  406 

causes  of,  407 

diagnosis  of,  468 

Cabot's  injection  method,  408 

extraperitoneal,  406 

intraperitoneal,  406 

prognosis  of,  409 

symptoms  of,  407 

treatment  of,  410 


Rupture  of — Continued 
urethra,  90 

complete,  of,  91 

consequences  of,  92 

diagnosis  of,  92 

with  extravasation  of  urine.  92 

hemorrhage  from,  92 

partial,  of,  91 

penile,  90 

perineal,  91 

with  urinary  retention,  92 

symptoms  of,  91 

treatment  of,  93 
Russian  clap,  125,  166 

Saddle  back  nose,  932 

Sadism,  814 

Salivation  in  antisyphilitic  treat- 

iLENT,  1012 
Salpingitis,  gonorrhceal,  169,  176 
Santorini,  plexus  of,  390 
Sarcoma  of 

bladder,  487 

kidney,  605 

prostate,  775 

spermatic  cord,  704 

testicle,  668 
Satyriasis,  811 
Sciatica,  syphilitic,  921 
Scleritis,  syphilitic,  924 
Scleroderma  of  meatus,  209 
Sclerosis,  disseminated  spinal,  996 
Scrotal  urethra,  218 
Scrotum 

anatomy  of,  615 

cancer,  chimney  sweep's,  625 

cysts  of,  626 

dartos  of,  615 

deformities  of,  620 

eczema  of,  622 

elephantiasis  of,  624 

emphysema  of,  621 

epithelioma  of,  625 

erythema   intertrigo  of,  621 

fibroma  of,  626 

gangrene  of,  623 

hydrocele  of,  677 

injuries  of,  620 

lipoma  of,  626 

molluscum  contagiosum,  623 

cedema  of,  621 

pediculosis  of,  623 


1078 


INDEX. 


Scrotum — Continued 

pruritus  of,  622 

sebaceous  cysts  of,  623 

steatoma  of,  623 

tumors  of,  625 

wounds  of,  620 
Segkegation  of  ukine,  380 

SEMEiSr,   CHARACTER  OF,   778 

Seminal  vesicles 
abscess  of,  712 
anatomy  of,  619,  70S 
anomalies  of,  711 
cancer  of,  718 
concretions  of,  716 
cystic  swelling  of,  715 
cysts  of,  715 
emissions  from,  795 
diurnal,  795 
incontinence  of,  796 
nocturnal,  795 
function  of:,  712 
gonorrhoea  of,  108,  711 
inflammation  of,  711 

(see  S,  vesiculitis) 
injuries  of,  711 
malignant  disease  of.  718 
syphilis  of,  965 
tuberculosis  of,  716 
Semixal  vesiculitis,  716 
( Spermatocystitis ) 
acute,  711 

causes  of,  711 
diagnosis  of,  712 
prognosis  of,  713 
symptoms  of,  711 
treatment  of,  714 
chronic,  713 
causes  of,  713 
diagnosis  of,  713 
symptoms  of,  713 
treatment  of,  714 
irrigation,  714 
massage,    715 
gonorrhceal,   108,   191 
syphilitic,  965 
tuberculous,  716 
diagnosis  of,  716 
treatment  of,  717 
castration,  717 
excision,  717 
Senator's    statistics    of   malignant 
disease  of  kidneys,  605 


Serpiginous  chancroid,  41 
chancre,   830 
syphilide,   880,   885 
Sexual 

anaesthesia,  813 
erethism,  9 
hypersesthesia,  805 
neuroses,  786 
psychopathies,  805 
anaesthesia,  813 
classification,  805 
homosexuality,  815 
androgyny,  817 
eff'emination,  817 
gynandry,  817 

psychical  hermaphroditism,  81( 
urnings,  816 
viraginity,  817 
hypersesthesia,  805 
masturbation,  806 

(Onanism) 
nymphomania,  811 
satyriasis,  811 
paresthesia,  814 
algolagnia,  814 
masochism,  814 
sadism,  814 
treatment  of,  817 
Sheath  of  penis,  2 
Sinus  pocularis,  70 
Smegma,  2 

Snuffles,  syphilitic,  981 
Sounds,  steel,  229 
Space  of  Retzius,  427 
Spasmodic   urethral  stricture,   204, 

256 
Specific  gravity  of  urine,  335 
Spermatic  cord,  702   (see  Cord) 

plexus,  705 
Spermatocystitis,  711 

(see  Seminal  vesiculitis) 
Spermatorrhoea,  796 
character  of,  796 
diagnosis  of,  796 
treatment  of,  796 
Spermaturia,  357 
Sphincter,  external  \tesical,  70 

internal  vesical,  70 
Spinal  sclerosis,  syphilitic,  996 

in  urethral  stricture,  227 
Spleen,  syphilis  of,  957,  997 
interstitial  splenitis,  997 


INDEX. 


1079 


Spongy  body  of  penis,  1 

uietlu'a,  68 
Steatoma  of  scrotum,  623 
Sterility,  800 
aspermia,  800 
causes  of,  800 
false,  800 
malemissioii,  800 
azoospermia,   801 

in  Rontgen  ray  workers,  802 
from  epididymitis,  648,  679 
from  hydrocele,  double,  679 
oligospermia,  801 
oligozoospermia,   801 

in  urethral  stricture,  227 
treatment  of,  802 

anastomosis  of  vas,  802 
Stomatitis,    acute   gonorrhceal,    194 
Stone   (see  Calculus) 
prostatic,   773 
renal,  550 
subpreputial,  7 
ureteral,  515 
urethral,  99 
vesical,  440 
Stone  searcher,  vesical,  446 
Stricture  of  ureter,  513 
Stricture  of  urethra  (male) 
acquired,  203 
annular,  208 
calibre,  large,  209,  211 
calibre,  small,  209,  211 
cicatricial  208 
clinical  forms,  207 
congenital,  203 
contractile,  209 
diagnosis  of,  220 

method  of  examination,  220 
in   prostatic  hypertrophy,   223 
dribbling  in,  210,  217 
gleet  in,  210,  218 
gonorrhceal,  205 
impermeable,  209 
inflammatory.  203 
irritable,  209 
linear,  207 
location  of,  211 
multiple,  212 
organic,  205 
causes  of,  205 
frequency  of,  205 
rapidity  of,  207 


Stricture  of  Urethra   (male) — Cont. 
pathology  of,  213 
permeable,  209 
recent,  208 
recurring,  209 
resilient,  208 
results  of 

bladder  hypertrophy,  227 
calculus,  vesical,  227 
extravasation  of  urine,  223 
fistula,  227 
impotence,  227 
kidney,  infected,  227 
pyelonephritis,  227 
surgical,  227 
spinal  sclerosis,  227 
sterility,   227 
ureteral  dilatation,  227 
hydronephrosis,  227 
retention  of  urine,  227 
prognosis  of,  227 
residual  urine  in,  227 
simple,  209 
single,  212 
soft,  208 
spasmodic,  204 
causes  of,  204 
diagnosis   of,   204 
treatment  of,  205 
summary  of  treatment  of,  255 
symptoms  of,  216 
constitutional,  218 
objective,  218 
subjective,  216 
tortuous,  208 
traumatic,  207,  212,  215 
treatment  of  organic,  228 
dilatation,  228 
continuous,  241 
gradual,  228 

complications  of,  239 
indications  for,  237 
instruments  for,  228 
method  of,  228 
urethral  antisepsis,  230 
meatotomy,  243 

in  children,  247 
perineal  section,  247,  251 
suprapubic  cystotomy,  253 

retrograde  catheterizacion,  253 
traumatic  urethritis,  253 
urethrotomy,  241 


1080 


INDEX. 


Stricttjbe  of  Urethra    (male) — Cont. 
combined     internal     and     ex- 
ternal, 250 
advantages  of,  250 
indications  for,  251 
method  of,  250 
external    perineal,   247 
(Syme's  operation) 
drainage  in,  253 
indications  for,  249 
method  of,  247 
perineal  section,  251 

indications   for,   252 
method   of,    251 
prognosis  of,  250 
internal,   241 

antisepsis  in,  242 
in  children,  247 
hemorrhage  in,  242 
indications  for,  243 
methods  of,  244 
summary  of  treatment,  255 
urethrectomy,  254 
treatment  of 
divulsion,  254 
electrolysis,  254 
excision,   254 

with  transplantation,  254 
Stricture  of  iirethra    (female) 
congenital,  256 
inilammatoiy,   256 
organic,  256 
causes  of,  256 
diagnosis  of,  257 
location  of,  256 
pathology  of,  256 
prognosis  of,  257 
symptoms  of,  257 
spasmodic,   256 
treatment  of,  257 
Stuttering  urination,  293 
Subcapsular    decortication    of    kid- 
ney, 602 
subpreputial  caiculi,  7 

chancroid,  45 
Succus    axterans    in    treatment    of 

syphilis,  1042 
Suppression  of  urine,  293 
non-obstructive,  294 
obstructive,  294 
Suprarenal  capsule  of  kidney 
abscess  of,  613 


Suprarenal  Capsule  of  Kidney — Cont. 
cysts  of,  614 
hypernephroma  of,  614 
tumors  of,  606,  613 
treatment  of,  613 
Suspensory  ligament  of  penis,  2 
Swinburne's  urethroscope,  275 
Syme's  operation  for  urethral  stric- 
ture, 247 
grooved  staff,  248 
Symptomatology  of  diseases  of  uri- 
nary tract,  285 
alteration    in     urinary    stream, 

293 
frequency  of  urination,  289 

Fenwick's  tables,  290 
haematuria,  329 

treatment,  333 
incontinence,   322 
pain,    character    and    intensity, 
285 
region,  286 

relation  to  micturition,  2SS 
retention  of  urine,  294 
suppression  of  urine,  293,  335 
Synorchism,  628 
Synovitis 

gonorrhoeal,  199 
syphilitic,  944 
acute  monoarticular,  945 

polyarticular,    944 
chronic  hypertrophic,  945 
(Hydrarthrosis) 
Syphilis 

acquired,  818 
acne  in,  859 
alopecia  in,  857,  887 
of  anus,  901 
of  arteries,  950 
arteritis,  950 
gummatous.  950 
sclerosis,  950 
arthralgia  in,  944 
arthritis,    gummatous    in,    945 
atypical,  819 
bladder,  436,  960 
bones,  859,  938 
brain,  904 
breast,  967 
bronchi,  936 

gummatous  ulcerations  of,  936 
mucous  patches  of,  936 


INDEX. 


1081 


Syphilis,    acquired — Continued 
bulls,  881,  978 
bursae,  947 
cephalalgia,  859,  909 

parasyphilitic,  913 

prodromal,  913 

secondary,   910 
chancre  in,  824 
choroid  in,  926 
choroido-retinitis,  926 
ciliary  body  of  eye  in,  926 
circulatory  system  in,  949 
Colle's  immunity  in,  819 
conceptional,  972 
condyloma,   864 
constitutional,  849 

diagnosis,   850 
contagion  in,  820 
cornea,  923 

keratitis,   interstitial,   923 
punctate,  924 
cranium,  942 
cyclitis,  926 

serous,  925 
dactylitis,  943 
ear,  928 

otitis  media,  929 
eburnation,  939 
ecthyma,  861,  874 
endocarditis,  949 
epididymis  in,  859,  960 
episcleritis,  924 

eruption    of    mucous    membranes, 
857 

of  skin,  854 
erythema,  857,  861,  890 

of  larynx,  934 
etiology  of,  818 
eye,   859,   923 
lids,  923 
fauces.  900 
fever,  852 
fingers,  943 
glands,  lymphatic,  846 
glossitis,  desquamative,  842 

gummatous,  895 

sclerous,  895 
gumma  of  skin,  881,  979 
diagnosis,  886,  980 
granuloma,  881 
location,  882,  884 
phagedenic,  885 


Syphilis,    acquired — Continued 
serpiginous,  885 
gums,  898 
heart,  949 

endocarditis,   949 

myocarditis,  949 

pericarditis,  949 
hepatitis,  gummatous,  954 

interstitial,  953 
hydrargjaism  in,  1016 
hj^drarthrosis  in,  945 
immunity,  against,  819 
impetigo,  873 
incubation 

primary,  824 

secondary,  848 
insontium,   826 
of  intestines,  901 
.intractable,  treatment  for,  1042 
iodism,  1019 
irido-cyclitis.  926 
iris,  859,  924 
iritis,  gummatous,  925 

parenchymatous,  924 

serous,  925 
joints,  859,  944 

arthalgia,  944 

arthritis,  gummatous,   945 

synovitis,  944 

acute  monoarticular,  945 

polyarticular,  944 
chronic  hypertrophic,  945 
( Hydrarthrosis ) 
keratitis,  interstitial,  923 

punctate,  924 
kidney,  958 

amyloid  degeneration,  959 

nephritis,  acute  parenchymatous, 
958 
gummatous,  959 
interstitial,    959 
lachrymal  apparatus,  923 
larynx,  934 

erji:hema,  934 

gummata,  circumscribed,  934 

gummatous   infiltration,   diffuse, 
934 

mucous  patches,  934 
leucoderma,  876 
leucoplakia,  895 
lids,  eye,  923 
liver,  858,  953 


1082 


INDEX. 


Syphilis,    acquired — Continued 
amyloid  degeneration,   956 
precocious,  953 
tertiary,  953 

hepatitis,    gummatous,    954 
interstitial,  953 
lungs,  9 30 

gumma,  circumscribed,  937 
phthisis,  937 
pneumonia,  936 
pulmonitis,  gummatous,   9b  < 
sclerosis  diffusej  937 
lymphadenitis,  846 
lymphangitis,  846 
lymphatic  system.  851 
mammae,  967 
marriage  in,  973 
mastitis,   acute   irritative,   967 

gummatous,   968 
meningitis,  919 
mortality,  968 
mouth,  983 

mucous  membranes,  857,  889 
diagnosis  of,  893 
eruption  of,  857.  889 
mucous  psoriasis,  892 
m.uscles,  947 

myositis,  acute  irritative,  947 
chronic  interstitial,  947 
gummatous,  948 
myelo-syphiloses,  919 
myocarditis,   949 
nasal  cavities,  930 

gummatous    infiltration,    931 
rhinitis,  930 
nephritis,    acute    parenchymatous, 
958 
gummatous,  959 
interstitial,  959 
precocious.  958 
nerves,  858,  921 
neuralgia,  853 
cerebral,  909 
nose,  929 

saddle  back,  931 
ocular   muscle   palsies,   927 
oesophagus,  900 
onychia,  858,  887 
opaline  plaques.  892 
ophthalmoplegia.  928 
optic  nerve  atrophy.  927 
neuritis,  927 


Syphilis,    acquired — Continued 
orbit,  923 
orchitis 
acute,  962 
gummatous,  962 
osteomyelitis,   gtimmatous,   939 
osteo-periositis,  938 
osteophytes,  939 
ostitis,  gummatous,  939 

rarefying,  939 
otitis  media,  929 
ovaries,  966 

pain,  muscular  and  articular,  85? 
palate,  898 
pancreas,   957 
papular,  862,  890 
condyloma,  864 
diphtheroid,   891 
erosion,    890    .  . 
mucous  patch,  864 
vegetating,  891 
papulo-squamous,  866,  892 
diagnosis  of,  869 
gummato,  892 
scaly  patches,  892 
paralysis,    progressive,    915 
paralytic  dementia,  915 
paronychia,  888 
pathology  of,  854 
penis,  965 
pericarditis,  949 
periods  of,  823 
periostitis,   gummatous,   939 

precocious,  938 
phalanges,  943 
pharynx,  899 

cicatricial  contraction,  899 
gumma,  899 
phlebitis,  951 
phthisis,  937 
pigmentary,  876 
pneumonia,  936 
primary  incubation,  824 
primary  lesion  of,  824 

(see  Chancre) 
primary     lymphatic     involvement, 

846 
prognosis  of,  968 
prostate,  965 
psychoses,  915 
ptyalism,    1011 
pulmonitis,  gummatous,  937 


INDEX. 


1083 


Syphilis,  acquired — Continued 
pustular  syphilide,  870,  978 
pustulo-erustaeeous,  875 
pyorrhoea  alveolaris,  898 
rectum,  901 
retiform,  876 
retina,  927 
retinitis,   central,  927 

choroido-,   920 
rhinitis,  acute,  930 
atrophic,  931 
chronic,  930 

(Hypertrophic) 
rupia,  881 

saddle  back  nose  of,  931 
salivation,   1012 
sciatica,  921 
sclera,   924 
scleritis,    924 
seminal  vesicles,  965 
serijiginous,  875 
skin,   859 
spinal  cord,  917 

etiology  of,  917 
lesions  of,  917 
meningitis  of,  919 
myelo-syphiloses,  919 
acute,  919 
chronic,  919 
chronic,  919 
subacute,  919 
tabes  dorsalis,  920 
spleen,  957 
stomach,  901 
synovitis,   944 

acute  monoarticular,  945 

polyarticular,  944 
chronic  hypertrojjhic,  945 
syphilides,  854.  859 
tabes  dorsalis,  920 
tarsitis,  923 
tendons,  859,  948 
tenosjnioAutis,  948 
acute,  948 
chronic,  948 
gTimmatous,  948 
tertiary  period,  823 
testicles,    961 

orchitis,  acute,  962 

differential  diagnosis,  963 
gummatous,   962 
interstitial,  961 


Syphilis,  acquired — Ck)ntinued 
thrombosis,   9ol 
tibia,  943 
tongue,  894 
chancre,   894 

gumma,   circumscribed,   895 
( Gummatous  glossitis ) 
gummatous   infiltration,   diffuse, 
895 
(Sclerous  glossitis) 
mucous  patches,  894 
roseola,   894 
scaly  patches,  895 

(Syphilitic  leucoplakia) 
smooth  patches,  894 

(Desquamating  glossitis) 
ulcerations,   894 
tonsils,  900 
trachea,  936 

gummatous  ulcerations,  936 
mucous  patches,  936 
treatment,   1001 
abortive,  1004 

constitutional,  1007 
destruction      or     excision     of 

chancre,  1005 
exceptions.  1007 
indications  for,   1007 
constitutional,  1007 
continuous,   1009 
hygienic,   1008 
interrupted,  1009 
modified  expectant,  1009 
systematic,    1010 
iodides,   1014 
indications    for,    1016 
iodism,    1019 

treatment  of,   1020 
mixed,   1014 
preparations,  1041 
toxic  effects.  1019 
use   of,   1039 
mercury,  1010 
baths,  1032 
electric,    1038 
hot,    10.34 

thermal  springs,   1033 
dose,  full,  of,   1011 
duration  of,  1013 
elimination  of,   1039 
hydrargyrism,  1016 
acute,  1016     . 


1084 


INDEX. 


Syphilis,    acquired — Continued 
chronic,  1017 
treatment  of,  1019 
hypodermic  injections,   1025 
contraindications,    1031 
indications  for,  1030 
preparations  for,  1031 
technique  of,  1026 
value  of,  1030 
intravenous         injections, 

1038 
inunctions,   1012,  1022 
preparations  of,  1010 
ptyalism,   1011 
salivation,  1012 
toxic  effects  of,   1016 
vaporization,    1031 
local,  1044 

of  chancre.  1044 
of  syphilide,  1044 
prophylactic,  1001 
vegetable,   1042 

McDade's  formula,  1042 
Taylor's  tonic,  1042 
Zittman's,   for   intractable   syph- 
ilis, 1042 
tubercular,  877 
character,  877 
non-ulcerating,  877 

sequelae,  878 
serpiginous,  880 
ulcerating,   879 
character,  879 
location,  880 
ureters,  960 
urethra,  965 
uterus,  859,  966 
vagina,  966 
vas  deferens,  965 
veins,    951 
phlebitis,  951 
thrombosis,  961 
vertebrae,  943 
vesicular,  869,  978 
diagnosis  of..  870 
rarity  of,  869 
treatment   of,   870 
varieties  of,  870 
viscera,  858 
vulva,'966 
hereditary,  975 

albuminuria  in,  997 


Syphius,    hereditary — Continued 
alopecia  in,  980 
amorphism,  987 
appearance  of  child  in,  976 
blepharitis,  marginal,  982 
bones,  988 
brain,  993 

disturbed  cerebration,  994 
bullae,  978 
ceplyilalgia,  994 
choroiditis,  983 
dactylitis,   991 
deafness,  983 
ear,  983 

deafness,  983 

otitis  media,  983 

tinnitus,  984 
epididymis,  997 
eijileptic,  994 

epiphyseal   malformation,   992 
erythema,  977 
eye,  982 

blepharitis,  marginal,  982 

choroiditis,  983 

iritis,  983 

keratitis,  interstitial,  982 

lachrymal  apparatus,  982 

optic  neuritis,  983 

retinitis,  983 
face,  989 
gumma,  979 
hair,  980 
hepatitis,   gummatous,   996 

interstitial,  996 
Hutchinson's  teeth,   986 
hydrarthrosis,   chronic,  992 
intestines,  997 
iritis,    983 
joints,  992 

epiphyseal  malformations,  992 

hydrarthrosis,    chronic,    992 

osteophytes,  992 

Avhite  swelling,  992 
keratitis,  interstitial,  982 
kidneys,  997 

albuminuria  in,  997 
lachrymal  apparatus,  982 
liver,  996 

hepatitis,  gummatous,  996 
interstitial,  996 
lungs,  996 

gumma,  996 


INDEX. 


1086 


Syphilis,  hereditary — Continued 
inliltration,  996 

( White   pneumonia ) 
microcephalus,  989 
microdontisnij  987 
nnicovis  membranes,  981 

patches,  977 
nails,  980 
neuritis,  optic,  983 
nose,  989 
onychia,  980 
optic  neuritis,  983 
osteochondritis,   988 
osteophytes,  992 
ostitis,  rarefying,  989 
otitis  media,  983 
pancreas,  997 
papular,  977 
Parrot's  nodes,  989 
pneumonia,  989 
pustular,  978 
retinitis,  983 
roseola,  977 

sclerosis,  disseminated,  99G 
skin,  976 
skull,  989 
spinal  cord,  995 

sclerosis,   disseminated,   9f!6 
tabes,  995 
spleen,  997 

splenitis,    interstitial,    997 
stages,  976 
symptoms  of,  975 
syphilides,  979 
tabes,  995 
teeth,  984 

amorphism,  987 

erosion,  985 

Hutchinson's,  986 

microdontism,  987 
tibia,  sabre-shaped,  989 
tinnitus,  984 
treatment  of,   1048 

of  child,  1049 

of  mother,    1048 

of  nvirsing  mother.  1051 

prophylactic,   1048 

routine,  1049 
tubercular   syphilide.  979 
vesicular,  978 
Avhite  pneumonia,  996 

swelling,   992 


Syphilis — Continued 
heredity,  969 

conceptional,  972 

direct  foetal  infection,  971 

maternal,   970 

mixed,  970 

mortality  of,  970 

paternal,  969 

postconceptional,  970 

prognosis  of,  974 

seminal   transmission,   969 

Tabes  dobsalis,  920,  995 
Tabsitis,  syphilitic,  923 
Teale's  pbobe  goeget,  247 
Teeth,  syphilis  of,  984 

Hutchinson's,  986 
Teevan's  ueethbotome,  244 
Tenesmus,  vesical 

in  stricture  ^of  the  urethra,  217 
in  wounds  of  the  bladder,  403 
Tenosynovitis 
gonorrhoeal,  201 
syphilitic,  948 
acute,  948 
chronic,  948 
gummatous,   948 
Tensile  strength  or  penis,  3 
Testicle 

abscess  of,  656 

tubercular,   6.j8 
anatomy  of,  615 
anomalies  of,  626 

abdominal  retentiort,  629 
anorehism,  627 
bilateral,  627 
monorchism,  627 
arrest  of  passage,  629 
atrophy  of,  628 
cryp  torch  ism,  629 

complications  of,  (>W 
treatment  of,  636 
diagnosis  of,  632 
prognosis  of,  632 
treatment  of,  633 
varieties  of,  629 
ectopy,  629,  633 
orchidopexy,  634 
treatment  of,  634 
varieties  of,  629.  633 
hypertrophy,  628 
polyorchism,  626 


10S6 


INDEX. 


Testicle,    anomalies    of — Continued 

synorcliism,   628 
cancer  of.  665 

character  of.  666 

diagnosis  of.  666 

etiology  of,  665 

prognosis  of,  668 

:^jTnptoms  of,  666 

treatment  of,  668 
castration,  675 

indications  for,  675 

technique  of,  676 
contusions  of.  639 

prognosis  of,  640 

symptoms  of,  640 

treatment  of,  641 
cyst  of,  669 

diagnosis  of,  672 

symptoms  of^   672 

treatment  of,  673 
cj-stoma  of,   669 
dermoid  cyst  of,  674 
enchondroma,  673 
epididjTno-orchitis,  652 

(see  Epididymo-orchitis) 
fibroma  of.  674 
fungus  of,  657 
gangrene  of,  657 
hiematocele,  697 
hernia,  657 
hydrocele,   669    (see   Hydrocele) 

acute,  678 

chronic,  680 

encysted,  669 

patholog;s"  of,  677 
inflammation    of,    644    (see   Orchitis 

and    Epididymo-orchitis ) 
injuries,  639 
inversion  of,  637 

diagnosis  in'  hydrocele,  637 
luxation,  638 
lymphadenoma,  673 
myoma,  675     ' 
myxoma,  675 
necrosis,  657 
neuralgia,  700 
osteoma,  675 
retention   of,   629 
sarcoma,  668 

strain,    iiiflammation    from,    642 
syphilis  of,  664,  960,  997 
torsion  of.  638 


Testicle — Continued 
tuberculosis  of,  658 
diagnosis,  661 
etiologj^,  658 
prognosis,  662 
symptoms,  660 
treatment,  663 
palliative,  663 
radical,  663 
castration,  663 
tumors  of,   665 
wounds,   643 
treatment,  644 
Thiersch's   opekatiox  for  epise.vdia, 

83 
Thompson's  steel  urethral  souxds, 
229 
stone  searcher,  446 
Thrombosis,  syphilitic,  951 
Tibia,  syphilis  of,  943,  989 

sabre-shaped,    989 
TixN'iTUs,  syphilitic,  984 
Tissue  ix  urixe,  354 
Toxgue,  chaxcre  of,  841 

syphilis   of,   841,    894 
Tonsils,    chaxcre   of,    842 

syphilis  of,  842,  900 
Torsioxof  pexis,  5 

of  testicle,  638 
Tortuous  urethral  stricture,  208 
Traumatic  urethritis,   102 

tuethral  stricture,  207,  212 
Trepoxema  pallidum,  sis 
Trigoxum   of   bladder,    3S9 
Tubercular  chaxcroid,  44 
funiculitis,  703 
syphilide,  877 
virethritis.  Ill 
Tuberculosis  of 
bladder,  428 
diagnosis,  432 
etiology,   429 
haematuria  in,  332 
modes  of  infection,  430 
pathological  anatomy,  430 
prognosis  of,  433 
symptoms  of,  431 
treatment  of,  433 
operative,  435 
epididymis,  658 
kidnev.  596 


IIsDEX. 


1087 


Tuberculosis    of    Kidney — Continued 
diagnosis  of,  600 
haematuria  in,  332 
prognosis  of,   601 
symptoms  of,  598 
treatment  of,  601 
prostate,  731 

diagnosis  of,   733 
prognosis  of,   733 
symptoms  of,  732 
treatment   of,    733 
seminal  vesicles,  717 
spermatic  cord,  704 
testicle,  658 

diagnosis  of,  661 
etiology  of,  658 
prognosis  of,  662 
symptoms  of,  660 
treatment  of,  663 
palliative,   663 
radical,  663 
castration,  663 
ureters,  522 
Tumors  of 
bladder,  485 
epididymis,  665 
kidney,  602 
prostate,  775 
scrotum,  625 
seminal  vesicies,  716 
-permatic  cord,   703 
suprarenal   capsule,   606 
testicle,  665 
ureter,    523 
Tunica  vaginalis 
anatomy  of,  677 
haematocele,  694 
hydrocele,  680 
inflammation  of,  678 
loose  bodies  in,  700 
Typhotdal  urethritis,  112 
Tyrosin  in  the  urine,  359 
Tyson,  glands  of,  2 
cysts  of,  60 

Ulcus  elevatum,  41 

Ultzman's     injection     for     gonor- 

RHCEA,     145 

Urachus,  387 

cyst  of,  592 

patent,  397 
Urea  in  urine,  329 


Ureter 

anatomy  of,  504 
anomalies  oi,  506 

valve  formation,  507 

Fenger's  operation,  507 
calculus  ofj  515 

diagnosis  of,  516 

location  of,  515 

mortality  of,  521 

prognosis  of,  518 

symptoms  of,  515 

treatment  of,  518 

uretero-lithotomy.  519 
catheterization  of,  379,  595 

instruments,   379 

segregation  of  urine,  380 

technique,  379 
cysts,  523 
derivation    in   exstrophy   of   bladder, 

397 
dilatation  in  urethral  stricture,  227 
fistula,  521 

imperforate    (congenital),  589 
implantation  of,  395,  509,  511 

Penrose's  method  for  rupture,  511 

Van   Hook's   method   for    rupture, 
509 
inflammation  of,  512 
(see  Ureteritis) 
injuries  of,  507 
palpation  of,  512 
prolapse  of,  523 
rupture  of,  507 

pseudo-nephrosis,  507 

treatment,  508 
stricture,  513 

complications  of,  514 

diagnosis  of,  513 

in  hydronephrosis,  590 

prognosis  of,  514 

symptoms  of,  513 

treatment  of,  514 

varieties  of,  513 
syphilis  of,  960 
tuberculosis   of,   522 
tumors  of,  523 
valve  formation,  507 
wounds  of,  507 
Ureteritis,  512 

cystoscopie  diagnosis  in.  376 
gonorrhoeal,   192 
I    Ureterolithotomy,  519  - 


1088 


INDEX. 


Ubethra 
abscess   of    (perivirethral) , '^88 
absence  of,   71 
anatomy  of   male,   G8 
anomalies  of,  71 
anterior  erectile,   71 
atresia   of^   71 
bulbous,  69 
calculus  of,  99  • 

character  of,  99 

diagnosis  of,  100 

location  of,  99 

symptoms  of,  100 

treatment  of,  101 
calibre  of,  220 
cancer    (carcinoma)   of,   107 
caput  gallinaginis,  70 
caruncles,  270 
chancre,   109,  838,  965 
chancroid,  110 

compressor  urethrae  muscle,  70 
congenital  stricture  of,  72 
deformities  of,  71 
discharge  from,  102 

examination   (microscopic)   of,  117 

prostatorrhcea,  792 

source  of,  118 

spermatorrhoea,  796 

urethritis,  103 

urethrorrhoea,   102 

varieties  of,  117 
diverticula,  73 
double,  73 
epispadia,  81 

treatment  of,  83 
epithelial  lining  of,  68 
external  vesical   sphincter  of,   70 
false  passages  of,  239 
fistula,  262 

urethro-penile,  267 

urethro-perineo-scrotal,   265 

urethro-rectal,  262 
foreign  bodies,  95 

consequences  of,   97 

diagnosis  of,  97 

symptoms  of,  96 

treatment  of,  97 
fossa  navicularis   in,  68 
glands  of  Littre  in,  69 
gonorrhoea  of,  103 

(see  Urethritis) 
hypospadia,  73 


Ubethra — Continued 
balanic,  73 
causes  of,  74 
diagnosis  of,  77 
forms  of,  73 
glandular,   73 
penile,   73 
perineal,   73,   76 
prognosis  of,  77 
treatment  of,  77 
inflammation  of,  163 
(see  Urethritis) 
injuries  of.  89 

internal   vesical   sphincter   of,   70 
malformations  of.  71 
meatus  of,  68 
membranous,  68 
mucous  membrane  of,  68 
multiple,  73 
obstruction  of.  71 
papilloma  of,  269 
pendulous,  69 
penile,  1,  68 
physiological  action,  70 
dilatation,  68 
narrowing,  68 
posterior  muscular,  71 
pouches  of,  73,  268 
prostatic,  68 
ducts  of,  70 
sinus  of,  70 
reflex  spasm  of,  70 
rupture  of,  90 
complete  of,  91 
consequences  of,  92 
diagnosis  of,  93 
hemorrhage  from.  92 
partial,  91 
penile,  90 
perineal,  91 

retention  of  urine  in,  92 
symptoms  of,  91 
treatment  of.  93 
urinary   extravasation   from,   92 
sinus  pocularis  of,  70 
-spongy,  68 

stricture    ( see  Stricture ) ,   203 
submucous  tissue  of,  68 
syphilis  of,  109,  838,  965 
tuberculosis  of,  111 
tumors  of,  269 
caruncles,  270 


INDEX. 


1089 


UEETHnA,  tumors  of — Continued 
papillomata,  269 
polyps,  269 
Avounds  ofj  89 
Ubethral  fever,  258 

(Urinary  fever) 
acute,  259 
chronic,  260 
etiology  of,  258 
jjrognosis  of,  260 
reflex  element,  258 
symptoms  of,  259 
treatment  of,  261 
Urptheal  instruments 
care  of,  279 
sterilization  of,  280 
Urethral  shreds,  102,  104,  117 
Ueethkectomy,  254 
UeethritiSj  102 

ardor  urinse  in,  105,  121 
from  cancer  of  urethra,   107 
chancroidal.    111 
chronic,  208 
classification  of,   102 
concimitant,   108 
diathetic,  106 
diphtheritic,  113 
erethismic,  106 
eruptive,  107 
etiology  of,  102 
gonorrhoeal    (in  children) 
female,  181 

urethro-vulvo-vaginitis,   181 
catarrhal    (irritative),  181 
gonorrhoeal,  182 
male,  179 
gonorrhoeal   (female),  170 
acute,  170 
chronic,  170 
complications  of,  173 
contagion  of,   168 
diagnosis  of,  169,  171 
frequency  of,  168 
prognosis  of,  171 
symptoms  of,  170 
treatment  of,  J72 
gonorrhceal   (male),  103 
acute  anterior,  119 

complications  of,  125 
diagnosis  of,  115 
prognosis  of,  125 
symptoms  of,  119 


Urethritis — Continued 

albuminuria,    124 
ardor  urinse,  121 
chordee,  122 
constitutional,  125 
discharge  from,   120 
hsematui'ia,   124 
inflammatory,  119 
nocturnal  emissions,  124 
pain,  perineal,   124 
prodromal,  119 
urination,  frequent  and  ur- 
gent, 123 
treatment  of,  126 
abortive,  126 
prophylactic,    126 
systematic,  128 
dietetic,   129 
hygienic,  130 
injections,  133 
irrigations,  138 
therapeutic,    130 
acute  posterior,  121 

complications  of,  123 
cystitis,    123 
epididymitis,  123 
prostatitis,  123 
urethrocystitis,  123 
vesiculitis,  123 
diagnosis  of,  121 
symptoms,  prodromal,  of,   123 
treatment,  143 
catarrhal   (subacute),  145   . 
chronic   (gleet)    147 
anterior,  150 

diagnosis  of,   151 
discharge  from,   150 
prognosis  of,  152 
symptoms  of,   151 
treatment  of,   152 
diagnosis  of,   149 
etiology  of,  147 
pathology  of,  147 
posterior,  154 
diagnosis  of,  155 

Finger's  tables,  157 
pathology  of,   154 
prognosis  of,  156  ' 

symptoms  of,   154 
treatment  of,   156 
dilatation,  163 
instillations,   159  '   v 


69 


1090 


INDEX. 


Ubetheitis — Continued 

irrigations,   158 
ointments,  161 
summary,  164 
suppositories,   162 
clinical  forms^   166 
complications  of,  184 
abscess,  follicular,  188 
periurethral,  188 
prostatic,  190 
balanitis,  31,  184 
balano-posthitis,   31,   184 
bubo,  187 
cystitis^   192 
epididymitis,  191 
extragenital,  192 
eye,  194 

blennorrboea,  acute,  194 
conjunctivitis,  194 
ophthalmia,  194 
neonatorum,  195 
purulent,  194 
rheumatic,  198 
joints,  198 
lymphadenitis,  187 
lymphangitis,  187 
mouth.  194 

acute  stomatitis,  194 
nephritis,  192 
paraphimosis,  186 
pericarditis,  202 
phimosis,  185 
phlebitis,  202 
pleuritis,  202 
prepuce.  30 
proctitis,   193 
prostatitis.  190 
acute  simple,  190 
follicular,  190 
parenchymatous,   190 
pyelitis,  192 
rheumatism,  198 
arthritis,  199 
periarthritis,  200 
tenosynovitis,  201 
ureteritis,   192 
vesiculitis,  191 
diagnosis,  115 
etiology,  113 
gonococcus  of,  113^  120 
pathology  of,  118 
influenzal.  113 


Urethbitis — Continued 
ingestive,    105 
irritative,  105 
mechanical,  107 
pathology  of,   103 
pneumococcic,  113 
simple  infectious,  108 
specific,  108 
syniptomatologv",   104 
syphilitic,  109 
diagnosis  of,   109 
symptoms  of,  109 
treatment  of,  111 
traumatic,  102,  104,  253 
instrumentation,  104,  253 
irritating  injections,  105 
prognosis  of,  105 
symptoms  of,  105 
treatment  of,  105 
tubercular,   1 12 
typhoidal,  112 
varieties,   102 
Urethrorrhcea,  102,  271 
Urethroscopes,  273 
Urethroscopy,  273 
Urethrotomy,  241 

combined  external  and  internal,  250 

indications  for,  251 
external  perineal,  247,  251 
drainage  after,   253 
indications  for,  249,  252 
prognosis  of,   250 
internal,  242 

indications  for,  243 

URETHEO-VirLVO- vaginitis 

gonorrhoeal,  181 
Urine 

abnormal  substances  in 

air    ( pneumaturia ) ,  350 

albumin    (serum-albumin),  342 

albumoses   (albumosuria),  344 

bacteriuria,  350 

biliary  pigments  (choluria),  348 

blood   ( haematuria ) ,  345 

carbohydrates,  347 

chyle  (chyluna),  349 

cystin,  348 

diacetic  acid,  349 

fat   (lipuria),  349 

globulin,  344 

haemoglobin 

( Hsemoglobinuria ) ,   346 


INDEX. 


1091 


Ubixe — Continued 
sugars,  34? 
alterations  in 
color,  335 
normal  substances 

acetone,  341 

carbonates,  338 

chlorides,  336 

haematoporphyrin,    341 

oxalic  acid,  340 

phosphates,  338 

sulphur,  337 

urea,  339 

uric  acid,   339 

urobilin,  341 
quantity,  334 
reaction,   336 
specific  gravity,  335 
examination  for 
albumin,  361 
albumose,  363 
bile  pigments,  366 
blood  coloring  matter,  366 
Ehrlich's   diazo   reaction,   366 
indican,  365 
specific  gi'avity,  360 
sugar,  364 
extravasation  of,  223 
causes   of,   92,   223 
prognosis  of,  225 
symptoms  of,  223 
treatment  of,  226 
incontinence  of 

causes  of    (table),   322 
children,  in,  323 
diagnosis  of,  324 
treatment  of,  324 

mechanical,  325 

medical,  324 
epileptic,  323 
lesions   of  urinary  tract  as   cause 

of,  327 
retention  of,  294 

causes  of,  294,  299,  322 

congestive,   301 

effects  of,  297 

incomplete,  317 

inflammatory,   301 

obstructive,   302 

paretic,   300 

prostatic  enlargement,  in,  304 

diagnosis  of,  307 


Ukixe — Continued 

symptoms  of,  306 
treatment  of,  307 
stricture  in,  320 
treatment,  321 
symptoms  of,  294 
traumatic,  323 
sediments  in 
ciystalline 

in  acid  urine,  358 
in  alkaline  urine,  360 
non-crystalline 
bacteria,  355 
gonococcus,    354 
tubercle  bacillus,  353 
blood,  351 
casts,  356 
epithelium,  354 
parasites,    355 
pus,  352 

spermatozoa,  357 
tissue,   355 
segregation  of,  380 
suppression  of,  293,  335 
non-obstructive,  293 
obstructive,   293 
treatment  of,  294 
Urnings,  816 
Utekus 

gonorrhoea  of,  175 
syphilis  of,  966 

Vaginalitis,  acute,  678 

VAGI^SflSMUS,   799 

Vaginitis,  gonokrhoeal,  169,  177,  181 
urethro-A'ulvo-,   181 
vulvo-,  182 
Valentine's  endoscope,  273 
Van  Hook's   ureteral  transplanta- 
tion METHOD,  509 
Varicocele,  705 
causes  of,  705 
diagnosis  of,  706 
prognosis  of,   706 
symptoms  of,  706 
treatment  of,  706 
palliative,    706 
radical,  707 
excision,  707 
results,  708 
technique,  707 


1092 


INDEX. 


Vas  deferens 

anastomosis   of,   in   sterility   from 

epididymitis,   802 
anatomy  of,  618 
concretions  of,  716 
excision  of,  773 
syphilis  of,  965 
Vasectomy,  773 
Vasitis,  108 
Vegetable    treatment    of    syphilis, 

1042 
Vegetations,  syphilitic,  865 
Veins,  syphilis  of,  951 
Venereal  warts,  61 
Verruca,   61 

Vertebrae,  syphilis  of,  943 
Verumontanum,  70 
Vesical  calculus,  440 

(see  Calculus  of  bladder) 
Vesical  sphincter  muscles,  70 
Vesical   tenesmus   in    stricture   of 

urethra,  217 
Vesico-prostatic  plexus,  390 
Vesicular  syphilide,  869 
Vesiculitis,  711 
acute,  711 

causes  of,  711 
diagnosis  of,  712 
prognosis  of,  713 
symptoms  of,  711 
chronic,   713 
treatment,  714 
irrigation,  714 
massage,  715 
gonorrhoeal,   191 
tubercular,  716 
diagnosis  of,  716 
treatment  of,  717 
castration,  717 
excision,  718 
urethritis,  in,  108 


ViKAGINITY,     817 

Vulva,  syphilis  of,  966 
Vulvitis,  gonorrhceal,  173 
Vulvovaginitis 

catarrhal,   181 

gonorrhoeal,  182 

Warts,  venereal,  7,  34,  61 
diagnosis  of,  61 
prognosis  of,  62 
symptoms  of,  61 
treatment  of,  63 
Wassermann  reaction,  850,  851 
Wheelhouse's 

staff  in  perineal  section,  251 
tapering  gorget 

in  perineal  litholapaxy,  459 
in  perineal  section,  252 
White's   capsules  in  treatment  of 

urethritis,  131 
White      svi^elling,      syphilitic,      of 

JOINTS,  992 
Wood's  operation 

for  hypospadia,  80 
Wounds  of 
bladder,  402 
kidney,  544 
penis,  23 
prostate,  722 
scrotum,  620 
testicle,  643 
urethra,   89 

Young's    galvano-cautery   prostatic 
incisor,  754 

Zittman's    treatment    for    intract- 
able  SYPHILIS,    1042 


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